resp.system rosemary

8/3/2019 Resp.system Rosemary

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DiagnosisDiagnosis

Look at medical h istoryLook at medical h istoryPh ysical ExamPh ysical Exam

Assessment Assessment T est resultsT est results


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Th oracentesisTh oracentesis is a procedure to remove excessis a procedure to remove excessfluid in t h e space between t h e lungs and c h est fluid in t h e space between t h e lungs and c h est wall (pleural space)wall (pleural space)

Normally only @ 4 teaspoons t h ereNormally only @ 4 teaspoons t h ereIf more fluid builds up = pleuralIf more fluid builds up = pleuraleffusion presses on lungs . h ard to breat h eeffusion presses on lungs . h ard to breat h eDone to find cause of pleural effusion and easeDone to find cause of pleural effusion and easebreat h ing (fluid, h eart failure, lung cancer,breat h ing (fluid, h eart failure, lung cancer,tumors, embolism,tumors, embolism, etcetc))


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Prior toPrior to

Bleeding problemsBleeding problems Allergies (meds/latex) Allergies (meds/latex)

Explain procedureExplain procedure


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Procedure/RisksProcedure/Risks

Inserts needle or plastic tube draws out excessInserts needle or plastic tube draws out excessfluidfluidSend fluid for testingSend fluid for testing

RisksRiskspneumot h oraxpneumot h oraxsh ocksh ock

BleedingBleedingInfectionInfection


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DuringDuring

Sit on side of bed, c h air, etc.Sit on side of bed, c h air, etc.Lean forward and rest arms on table, etc.Lean forward and rest arms on table, etc.Instruct not to move, coug h , or breat h e deeplyInstruct not to move, coug h , or breat h e deeplyonce procedure startedonce procedure started

Area is Area is cleanssedcleanssedNeedle inserted between ribs into pleural spaceNeedle inserted between ribs into pleural space

May feel stinging, discomfort, pressureMay feel stinging, discomfort, pressureMonitor for s h ockMonitor for s h ock


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After After

Position side lying wit h unaffected sidePosition side lying wit h unaffected sidedown for at least an h ourdown for at least an h ourMay h ave c h est xMay h ave c h est x--rayrayReport fever, c h ills, redness, swelling,Report fever, c h ills, redness, swelling,bleeding or drainage at site, difficultybleeding or drainage at site, difficultybreat h ingbreat h ing


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Lung BiopsyLung Biopsy


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T ypesT ypes

Bronc h oscopicBronc h oscopic biopsybiopsy .Done using t h in, flexible.Done using t h in, flexiblebronc h oscope/or rigid. T akes @ 1 h r.. C h est xbronc h oscope/or rigid. T akes @ 1 h r.. C h est x--ray afterray after

Local anest h etic in mout h or nose tastes bitter,Local anest h etic in mout h or nose tastes bitter,mout h dry for several h ours, sore t h roat suckmout h dry for several h ours, sore t h roat suckonon lozengerslozengers or gargle. Avoid eating or drinkingor gargle. Avoid eating or drinkingfor @ 1 h our. May h ave slig h t fever for 24for @ 1 h our. May h ave slig h t fever for 24h oursh ours


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NeedleNeedle BiopsyBiopsy Use C T scan, ultrasound, orUse C T scan, ultrasound, orfluroscopeyfluroscopey to guide needle H old breat h e w h ileto guide needle H old breat h e w h ileneedle is inserted into lung and avoid coug h ing.needle is inserted into lung and avoid coug h ing.

Feel burning w h en numbing site. NeedleFeel burning w h en numbing site. Needleinserted into c h est may feel s h arp pain for fewinserted into c h est may feel s h arp pain for fewseconds. Lie on side @ 1 h r. to allow needleseconds. Lie on side @ 1 h r. to allow needlesite to seal. X site to seal. X- -ray usually taken afterwardsray usually taken afterwards


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Open biopsy and video assistedOpen biopsy and video assisted t h

oracoscopict h

oracoscopicsurgery (VA T S)surgery (VA T S) Open c h est. E T tube and vent Open c h est. E T tube and vent assistance.assistance. Th oroscopeTh oroscope t h roug h incision int h roug h incision inch est. Will insert drain tube (c h est tube) closech est. Will insert drain tube (c h est tube) close

incision wit h sutures. T o h elp reincision wit h sutures. T o h elp re--expand lung.expand lung.Ch est xCh est x--ray, c h est tube set ray, c h est tube set up.. T iredup.. T ired for 1for 1 --22days due to anest h esia general muscle ac h es,days due to anest h esia general muscle ac h es,mild sore t h roat, some discomfort at site.mild sore t h roat, some discomfort at site.

Monitor for bleeding, some may be expectedMonitor for bleeding, some may be expected(small amount)(small amount)


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Risks of Lung BiopsyRisks of Lung Biopsy

Collapsed lung (pneumot h orax)Collapsed lung (pneumot h orax)H emorr h ageH emorr h ageInfectionInfectionSpasms of bronc h ial tubesSpasms of bronc h ial tubes

Arrh yt h mias Arrh yt h mias

RareRare deat h

from complicationsdeat h

from complications


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Monitor and Report Monitor and Report

Severe c h est painSevere c h est painLigh t h eadednessLigh t h eadednessDifficulty breat h ingDifficulty breat h ingExcessive bleedingExcessive bleedingCoug h ed up more t h an T BSP. of bloodCoug h ed up more t h an T BSP. of blood

FeverFever


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Lung BiopsyLung Biopsy

Normal.. T issueNormal.. T issue normal, no infection,normal, no infection,inflammation or cancerinflammation or cancer

Abnormal..Abnormal Abnormal..Abnormal cells andcells and tissue..maytissue..may bebedue to infection, lung diseases, cancerdue to infection, lung diseases, cancer

If cancer results can determine treatment If cancer results can determine treatment options (surgery, radiation, c h emot h erapy)options (surgery, radiation, c h emot h erapy)


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LUNG BIOPSY.LUNG BIOPSY.

Exhalation

Similar tec h nique is used underSimilar tec h nique is used under


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Similar tec nique is used underSimilar tec nique is used underfluoroscopic guidancefluoroscopic guidance

Usually 4Usually 4--5 specimens are5 specimens areobtainedobtainedLung parenc h yma isLung parenc h yma isobtained by tearing t h eobtained by tearing t h erespiratory bronc h iolesrespiratory bronc h iolesForceps to distal mayForceps to distal maycause pneumot h oraxcause pneumot h oraxForceps too proximal mayForceps too proximal maycause bleedingcause bleeding

I di i f flI di i f fl


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BIBI11 311 3

Indications for fluoroscopyIndications for fluoroscopy

T o localize abnormalitiesT o localize abnormalitiesT O h elp prevent pneumot h oraxT O h elp prevent pneumot h oraxT O extract foreign bodiesT O extract foreign bodiesT O perform biopsy or brus h ing of solitaryT O perform biopsy or brus h ing of solitarypulmonary nodulespulmonary nodulesT o improve diagnostic yieldT o improve diagnostic yieldT o detect pneumot h oraxT o detect pneumot h orax

Preventing bleeds after T BLBPreventing bleeds after T BLB


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BIBI11 411 4

Preventing bleeds after B BPreventing bleeds after B B

Avoid excessive suction after biopsy. Instead, use gentlebrief suction to assess degree of bleeding.

If bleeding is excessive: gently instill 5-10 ml iced-salinethrough FFB, wait for 30 sec, then suction gently.


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BIBI11 511 5

T BLB in Renal FailureT BLB in Renal Failure


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BIBI11 611 6

Ch

eck INR & platelet count Ch

eck INR & platelet count Bleeding time can be misleadingBleeding time can be misleadingCorrect INR and platelet count if necessary (< 1 .5,Correct INR and platelet count if necessary (< 1 .5,

>50,000)>50,000)

Risk of bleeding is about 8%Risk of bleeding is about 8%

Oth er antiplatelet agents and AnticoagulantsOth er antiplatelet agents and Anticoagulants


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BIBI11 711 7

Ot er antiplatelet agents and AnticoagulantsOt er antiplatelet agents and Anticoagulants

Aspirin Aspirin(1 )(1 )

,T

iclopidine need not be,T

iclopidine need not bediscontinueddiscontinuedWarfarin (Coumadin) s h ould be discontinuedWarfarin (Coumadin) s h ould be discontinueduntil INR < 1 .5until INR < 1 .5(or INR corrected using Fres h Frozen Plasma or Vitamin K)(or INR corrected using Fres h Frozen Plasma or Vitamin K)

I.V. H eparin s h ould be stopped 2I.V. H eparin s h ould be stopped 2- -6 h rs prior6 h rs priorto biopsy. C h eck P TT .to biopsy. C h eck P TT .Low molecular weig h t h eparin s h ould be h eldLow molecular weig h t h eparin s h ould be h eld1 2 h rs ( h old previous dose).1 2 h rs ( h old previous dose).S.Q. H eparin is safe and can be continued.S.Q. H eparin is safe and can be continued.Follow recommendations for all ot h er newerFollow recommendations for all ot h er newerantianti--coagulants and ot h er agents.coagulants and ot h er agents.


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OXYGENT H ERAPY OXYGENT H ERAPY

A tifi i l AiA tifi i l Ai


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Artificial Airways Artificial Airways

Nasop h aryngealNasop h aryngealOrop h aryngealOrop h aryngealEndotrac h ealEndotrac h ealNasotrac h ealNasotrac h ealT rac h eostomyT rac h eostomy

Cricoidt h

yroidotomyCricoidt h

yroidotomy


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T ranstrac h ealT ranstrac h eal OxygenOxygen

T t h lT t h l O g D liO g D li


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T ranstrac h ealT ranstrac h eal Oxygen DeliveryOxygen Delivery

Used for longUsed for long- -term deliveryterm deliveryof oxygen directly into t h eof oxygen directly into t h elungslungs

Avoids t h e irritation t h at Avoids t h e irritation t h at nasal prongs cause and isnasal prongs cause and ismore comfortablemore comfortableFlow rate prescribed forFlow rate prescribed for

rest and for activityrest and for activity

The transtracheal catheter is the flexible little tube that passes from the


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The transtracheal catheter is the flexible little tube that passes from thelower neck into the trachea (or windpipe) and delivers oxygen directly tothe lungs.

The tube is kept in place by a safety flange and a bead chain necklace.Catheters are made of a flexible plastic, and should be replaced every 90days (3 months) or if they start to become brittle, yellowed, or kinked.

The hoses that connect the catheter to the oxygen source come in manydifferent sizes, and feature a safety clip.

This safety clip attaches to the pants, skirt, shorts or dress waistband andhelps to absorb any accidental pulls on the hose. The SCOOP hose isdesigned to be worn on the right hip


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BenefitsBenefits


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BenefitsBenefits

Improved Comfort and ConvenienceImproved Comfort and ConvenienceImproved Self ImageImproved Self ImageLower Oxygen requirementsLower Oxygen requirementsIncreased mobilityIncreased mobilityGreater Exercise CapacityGreater Exercise Capacity

Ph ysiological BenefitsPh ysiological Benefits


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Ph ysiological BenefitsPh ysiological Benefits

Reduced Red Blood Cell Count Reduced Red Blood Cell Count ImprovImprov eded Blood Flow t h roug h t h e lungsBlood Flow t h roug h t h e lungsImproved oxygen during sleepImproved oxygen during sleepDecreased work of breat h ingDecreased work of breat h ingDecrease in # of Decrease in # of h ospitilizationsh ospitilizations

RisksRisks


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RisksRisks

Coug h ing t h at will subsideCoug h ing t h at will subsideInfection if not taken care of correctlyInfection if not taken care of correctlySubcutaneous emp h ysemaSubcutaneous emp h ysemaKeloids @ tract sometimesKeloids @ tract sometimes


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Endotrac h eal T ubesEndotrac h eal T ubes



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Ch osenCh osen initially as a means of providinginitially as a means of providinganan airwayairwayWh enWh en t h ere is an obstruction @ t h e levelt h ere is an obstruction @ t h e level

of of t h e epiglottis or belowt h e epiglottis or belowT oT o deliver an accurate O2 concentrationsdeliver an accurate O2 concentrations&& unable to clear secretionsunable to clear secretions

T oT o institute mec h anical ventilationinstitute mec h anical ventilation

Mout h Met h od of c h oice,Mout h Met h od of c h oice,easiereasier


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procedure, larger diameterprocedure, larger diametertube.tube. Th e largerTh e larger t h e tubet h e tube

.reduces t h e work of .reduces t h e work of breat h ing (breat h ing (WOBWOB))

HoweverHowever .. ..

UncomfortableUncomfortable for t h efor t h ept pt .movement .movement

..laryngeal damage .maylaryngeal damage .may

bitebite on tube &on tube &causecause airway occlusionairway occlusion

Types of Tubes


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Cuffed Short distance from tip. Balloon & circular.

Most common used.

Epiglottislarynx.trachea

When inflated, seal formed, allows mechanicalcontrol of pts. respirations & preciseconcentrations of O2 to alveoli

Fenestrated Has openings which are incontact with the mucosa

Checking Tube Placement


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g

Auscultate both sides of chest while manuallyventilating pt.

Why??....To assure sufficient amt. of air

exchange in lungs

Heard bilaterally & unable to speak

Phonation requires airwith an adequate seal.Now unable to direct air flow thru vocal cords,so, unable to speak!


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Checking Tube Placement

Placement confirmed by CXR

Must be 1-2 cm above the carina

Intubated approx. 10-14 days.MD todecide whether to trach & peg


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Documentation

Amt of air in cuff

L evel of the tube: measured in cm

Breath Sounds

Tolerance of procedure

Completion of CXR & ABGs

Minimal Leak T ec h niqueMinimal Leak T ec h nique


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Minimal Leak T ec h niqueMinimal Leak T ec h nique MOV Minimal Occlusive Volume: CarefulMOV Minimal Occlusive Volume: Careful

monitoringmonitoring & management & management of tube cuff pressuresof tube cuff pressures. . Th isTh isminimizes complicationsminimizes complications

Smallest Smallest amt. of amt. of air neededair needed to ach

ieve ato ach

ieve a seal sh

ouldseal sh

ould bebe usedused

An An adequate seal is ac h ieved if duringadequate seal is ac h ieved if during maximal mec h anicalmaximal mec h anicalventilation a slig h t air leak canventilation a slig h t air leak can be h eardbe h eard over t h e trac h ea (wit h over t h e trac h ea (wit h stet h oscopestet h oscope))

Ch eck daily, 1 5Ch eck daily, 1 5--20 mm H g cuff pressure, Above 20..tube too small20 mm H g cuff pressure, Above 20..tube too small

CaresCares


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CaresCares

Ambu Ambu, E T tube of same size @ bedside, ET tube of same size @ bedside

H umidification must drain water out of H umidification must drain water out of tubetube

Communication met h odCommunication met h od


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Orop h arngealOrop h arngeal/ /Nasop h arngealNasop h arngeal Airways Airways


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Orop h aryngealOrop h aryngeal airwaysairways

Keep t h e tongue fromKeep t h e tongue fromblocking t h e upper airwayblocking t h e upper airway

Allow for easier suctioning of Allow for easier suctioning of t h e airwayt h e airway

Used in conjunction wit h Used in conjunction wit h BVM deviceBVM device

Used on unconsciousUsed on unconsciouspatients wit h out a gag reflexpatients wit h out a gag reflex


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Inserting anInserting an orop h aryngealorop h aryngeal airwayairway

Select t h e proper size airway.Select t h e proper size airway.Open t h e patient s mout h .Open t h e patient s mout h .

H old t h e airway upside down and insert it inH old t h e airway upside down and insert it in

t h e patient s mout h .t h e patient s mout h .

Rotate t h e airway 1 80Rotate t h e airway 1 80 until t h e flange restsuntil t h e flange restson t h e patient s lips.on t h e patient s lips.


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Nasop h aryngealNasop h aryngeal


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airwaysairways Conscious patients w h oConscious patients w h o

cannot maintain airwaycannot maintain airway

Can be used wit h intact Can be used wit h intact

gag reflexgag reflex Sh ould not be usedSh ould not be used

wit h h ead injuries orwit h h ead injuries ornosebleedsnosebleeds


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Inserting a nasop h aryngeal airwayInserting a nasop h aryngeal airway

1 . Select t h e proper size airway.1 . Select t h e proper size airway.

2. Lubricate t h e airway.2. Lubricate t h e airway.

3. Gently pus h t h e nostril open.3. Gently pus h t h e nostril open.

4. Wit h t h e bevel turned toward t h e4. Wit h t h e bevel turned toward t h eseptum, insert t h e airway.septum, insert t h e airway.


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T rac h eostomy T ubesT rac h eostomy T ubes

T rac h eostomy: Purposes &T rac h eostomy: Purposes & Advantages Advantages


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1 . T o1 . T o maintain an artificialmaintain an artificial airwayairway22. Used to relieve upper. Used to relieve upper airway obstructionsairway obstructions in t h ein t h e

respiratory tract respiratory tract 33. Provides an alternate route to. Provides an alternate route to remove secretionsremove secretions fromfrom

trac h eatrac h ea && bronc h ibronc h i4. Provides a route for4. Provides a route for mec h anical ventilationmec h anical ventilation ..?? W h at ..?? W h at

typetype of of trac htrac h neededneeded5.5. Prevents aspiration of food orPrevents aspiration of food or vomitus fromvomitus from t h e p h arynxt h e p h arynx

intointo lowerlower respiratory tract respiratory tract

T rac h eostomy: DisadvantagesT rac h eostomy: Disadvantages


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y gy g

Normal protective coug h ing mec h anisms isNormal protective coug h ing mec h anisms isimpairedimpaired because of t h e inability to closebecause of t h e inability to closeepiglottisepiglottis tig h tly. Prevents necessarytigh tly. Prevents necessary inc.inc.intrat h oracicintrat h oracic pressurepressure

Inspired air bypasses upper airwayInspired air bypasses upper airway structures of structures of nose &nose &ph arynx, t h us, removing t h eph arynx, t h us, removing t h e filtering, warmingfiltering, warming, ,h umidification of inspired airh umidification of inspired air


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Lose ability to speakLose ability to speak normally.normally.BecauseBecause trac htrac h lies below t h e p h arynx &lies below t h e p h arynx &t h eret h ere is inadequate air pressure wit h inis inadequate air pressure wit h inlarynxlarynx to permit vocal cords toto permit vocal cords to functionfunction

Inc. risk of infections versus E TTInc. risk of infections versus E TT

NewNew T rac h eostomyT rac h eostomy


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yy

DoDo not manipulate,not manipulate, inc.inc. cuff deflation forcuff deflation for2424 h rsh rs..

Ch eckCh eck for bleeding & crepitusfor bleeding & crepitus

Ch ange dressings PRN; was h wit h N/SCh ange dressings PRN; was h wit h N/S

Cuff DeflationCuff Deflation


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SometimesSometimes is needed to decrease t h e pressureis needed to decrease t h e pressure

onon trac h ealtrac h eal mucosamucosa

RNRN must know: 1 . T ype of cuff, 2. MD order formust know: 1 . T ype of cuff, 2. MD order forinflationinflation & deflation, 3. Amt. of air& deflation, 3. Amt. of air requiredrequired

Inject Inject 11 --6 cc6 cc SLOWLYSLOWLY

Air Air inflates cuff & you can test ballooninflates cuff & you can test balloonClampClamp distal to balloondistal to balloonDeflationDeflation of balloon means t h e cuff is deflatedof balloon means t h e cuff is deflated

H eat & H umidificationH eat & H umidification


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Bypasses t h e natural processBypasses t h e natural processO2 s h ould be body temperatureO2 s h ould be body temperatureH ow?...t h ru a nebulizerH ow?...t h ru a nebulizerNebulizer attac h ed to h umidifier containingNebulizer attac h ed to h umidifier containing

sterile watersterile waterWit h ventilator t h ese 2 pieces are part of Wit h ventilator t h ese 2 pieces are part of mac h inemac h inePrevents encrustations & obstruction of airwaysPrevents encrustations & obstruction of airwaysLess likely to develop infectionsLess likely to develop infections

Disch argeDisch arge


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Cover neck wit h

scarf Cover neck wit h

scarf Room h umidifier in h omeRoom h umidifier in h omeKeepKeep trac htrac h inner tube dryinner tube dry


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Mech anical VentilationMech anical Ventilation


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Mech anical VentilationMech anical Ventilation


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T ypes are classifiedT ypes are classified accordint accordint to h ow t h eto h ow t h einspiration p h ase is terminatedinspiration p h ase is terminated

Volume Volume CycledCycledPressurePressure CycledCycledT imeT ime -- CycledCycled

Volume Cycled Ventilators Volume Cycled Ventilators


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yy

Used in COPD pts. Th e c h anges inUsed in COPD pts. Th e c h anges in lung compliancelung compliance &&resistance from COPDresistance from COPD will affect will affect t h e pressure it takes tot h e pressure it takes toprovideadequateprovideadequate ventilationventilation

Most Most commonly used vent in critical carecommonly used vent in critical carebecause of constancy of because of constancy of Vt Vt & O2& O2 delivereddelivered

End inspiration after delivering a preset End inspiration after delivering a preset volume of oxygenvolume of oxygen

Pressure Cycled VentilatorsPressure Cycled Ventilators


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yy

Respirations end w h en a preRespirations end w h en a pre- -set pressureset pressureis reac h edis reac h ed

V Variableariable & depends on airway pressure && depends on airway pressure &ComplianceComplianceIPPB devices are examples of pressureIPPB devices are examples of pressurecycledventilatorscycledventilatorsPressure assisted ventilators are used asPressure assisted ventilators are used asan adjunct an adjunct to t h e weaning processto t h e weaning process

T ime Cycled VentilatorsT ime Cycled Ventilators


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yy

T idal volume (T idal volume (Vt Vt) may not always be) may not always beconstant constant due to c h anges in airwaydue to c h anges in airwayresistanceresistance && compliancecompliance

Th e flow of gas into t h e patient endsTh e flow of gas into t h e patient endswh en awh en a pre set time h as elapsed after t h epre set time h as elapsed after t h estart of start of inspirationinspiration

Vent settings to improve Vent settings to improve


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F IO 2Simplest mane u ver to q u ickly increase P a O2Long-term toxicity at >6 0%

Free radical damage

Inadeq u ate oxygenation despite 1 00% F iO2u s u ally d u e to p u lmonary s h u nting

Collapse AtelectasisP u s-filled alveoli Pne u moniaWater/Protein ARDSWater CH F

Blood - Hemorr h age

PEEP and F iO2 are adj u sted in tandem


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Indications for ext u bationIndications for ext u bation


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Clinical parametersResol u tion/Stabilization of disease processHemodynamically stableIntact co u g h /gag reflexSpontaneo u s respirations

Acceptable vent settingsF iO 2< 50% , PEEP < 8 , P a O2 > 7 5 , pH > 7.2 5

G eneral approac h esSIM V Weaning

Pressu

re Su

pport Ventilation (PS V) WeaningSpontaneo u s breat h ing trialsDemonstrated to be superior

No weaning parameter completely acc u rate w h en u sed alone

Ventilator Settings Ventilator Settings


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FIO2:FIO2: Fraction of inspiredFraction of inspired oxygen concentrationoxygen concentration

IncreasedIncreased FI02 =FI02 = increasedincreased PO2PO2DecreasedDecreased FIO2 =FIO2 = decreaseddecreased PO2PO2

FIO2 varies:FIO2 varies: 0.2 1 (2 1 %) to 1 .0 ( 1 00%)0.2 1 (2 1 %) to 1 .0 ( 1 00%)UsuallyUsually set @ 0.40 (40%)set @ 0.40 (40%)

SettingsSettings are dependent on ABGare dependent on ABG resultsresults

T idal Volume:T idal Volume: Amount of oxygen delivered Amount of oxygen deliveredby eac h ventilatorby eac h ventilator contolledcontolled breat hbreat h

IncreasedIncreased T vT v = Decreased= Decreased PCO2PCO2DecreasedDecreased T vT v = Increased PCO2= Increased PCO2



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Th e number of ventilator controlledTh e number of ventilator controlledbreat h sbreat h s t h e mac h ine delivers int h e mac h ine delivers in one minuteone minute

IncreaseIncrease t h e rate = decrease in PCO2t h e rate = decrease in PCO2DecreaseDecrease t h e rate = increase t h et h e rate = increase t h e PCO2PCO2

SIM VSIM V: Sync h ronized intermittent: Sync h ronized intermittent ventilator ventilationventilator ventilation Allows Allows pt. to breat h on own betweenpt. to breat h on own between breat h s deliveredbreat h s delivered by ventilatorby ventilatorbreat h sbreat h sCanCan wean wit h wean wit h SIMVSIMV

SIMVSIMV gives respiratory muscles timegives respiratory muscles time to reconditionto reconditionForFor example: SIMV of 5; 20 breat h sexample: SIMV of 5; 20 breat h s on own=respiratoryon own=respiratory raterate



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Assist Control: Th e mec h anical ventilator Assist Control: Th e mec h anical ventilatordeliversdelivers enoug h breat h s to meet t h e pts.enoug h breat h s to meet t h e pts.needsneedsIf If pt. takes spontaneous breat h positive,pt. takes spontaneous breat h positive,t h et h e ventilator responds by delivering aventilator responds by delivering abreat h breat h as soon as pt. breat h sas soon as pt. breat h sPreset # of pressure breat h s @ a preset Preset # of pressure breat h s @ a preset Vt Vt



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PEEPPEEP: Amount of positive pressure applied: Amount of positive pressure applied @ @endend of inspirationof inspirationIncreasedIncreased PEEP = Increased PO2PEEP = Increased PO2

Positive End Expiratory PressurePositive End Expiratory PressureIncInc. t h e resistance to expiration;. t h e resistance to expiration; inc. inc. in amt.in amt. of of O2O2 t h at remains in t h e lungs duringt h at remains in t h e lungs during expiratoryexpiratoryph aseph ase .prevents alveolar collapse.prevents alveolar collapse

In a pt. that does breath spontaneously, the epiglottisprovides 5 cm of PEEP normally



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CPAPCPAP vsvs PEEPPEEP

ContinuousContinuous positive airway pressure Bot h improvepositive airway pressure Bot h improveoxygenationoxygenation byby incinc t h et h e ptspts functional residual capacityfunctional residual capacity

((FRC) t h e volume of air in t h e lungs @ end of FRC) t h e volume of air in t h e lungs @ end of expirationexpiration

CPAPCPAP can be provided using a specific CPAP device orcan be provided using a specific CPAP device oraa mask & may not require using a ventilatormask & may not require using a ventilator! !

CPAPCPAP used duringused during weaningweaning to reduce t h eto reduce t h e amt amt of energyof energyt h et h e pt pt expends to pull O2 t h ru ventilatorexpends to pull O2 t h ru ventilator

Nursing CareNursing Care


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Assess respiratory Assess respiratoryBilateral breat h soundsBilateral breat h soundsCrackles or r h onc h i: need to suctionCrackles or r h onc h i: need to suction

Position & security of tubesPosition & security of tubesSkin @ tubesSkin @ tubesCuff pressureCuff pressure

Comfort level/anxietyComfort level/anxiety Aerosol Th erapy Aerosol Th erapyH ydration/NutritionH ydration/Nutrition

Nursing CareNursing Care


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Never s h ut alarms off Never s h ut alarms off Major alarms: H igh Pressure: too muc h Major alarms: H igh Pressure: too muc h resistance .suction?resistance .suction?

LowLow pressure..not pressure..not meeting expected breat hmeeting expected breat h Alarm initiated: C H ECK PT . FIRS T Alarm initiated: C H ECK PT . FIRS T

Gasping, Cyanotic, etc.Gasping, Cyanotic, etc.Get h elp andGet h elp and ambuambu pt.pt.

WeaningWeaning


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SIMV used for patients t h at are difficult to weanSIMV used for patients t h at are difficult to weanPt Pt remains connected to vent & # of mandatoryremains connected to vent & # of mandatorybreat h s delivered by t h e mac h ine is graduallybreat h s delivered by t h e mac h ine is graduallyreduced allowing pt. to take increasing # of reduced allowing pt. to take increasing # of breat h s on ownbreat h s on own

PSV = Pressure support ventilation. All breat h sPSV = Pressure support ventilation. All breat h s

initiated by pt. & supplement wit h positiveinitiated by pt. & supplement wit h positivepressure. PSV augments pt. Provides reg.pressure. PSV augments pt. Provides reg.exercise for pulmonary musclesexercise for pulmonary muscles

Nursing CareNursing Care - - Ventilation Ventilation


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Goal is to reduce respiratory rate until pt.Goal is to reduce respiratory rate until pt.takes on breat h ing on owntakes on breat h ing on ownIf pt. can talk t h en t h e cuff is leaking if it If pt. can talk t h en t h e cuff is leaking if it is supposed to be cuffedis supposed to be cuffed trac htrac h

Vent manually w h ile you try to figure out Vent manually w h ile you try to figure out a problem if you can t fix immediately or if a problem if you can t fix immediately or if

it is low pressure meaning t h e pt. is not it is low pressure meaning t h e pt. is not getting enoug h oxygengetting enoug h oxygen


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CH EST T RAUMACH EST T RAUMA

Th oracic InjuryTh oracic Injury

Pneumot h oraxPneumot h orax


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Air between the pleurae is a pneumothoraxOccurs when there is an opening on thesurface of the lung or in the airways, in thechest wall or both

Can be from internalOr external injury

Open = sucking chestwound

Open pneumot h oraxOpen pneumot h oraxOpening in t h e c h est wall (wit h or wit h out lungOpening in t h e c h est wall (wit h or wit h out lung


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Opening in t e c est wall (wit or wit out lungOpening in t e c est wall (wit or wit out lungpuncture)puncture)

Allows atmosp h eric air to enter t h e pleural space Allows atmosp h eric air to enter t h e pleural spacePenetrating trauma: stab, guns h ot, impalement Penetrating trauma: stab, guns h ot, impalement SurgerySurgery

An An open pneumot h oraxopen pneumot h orax is also called ais also called a


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p pp p

sucking ch

est wound sucking ch

est woundWit h t h e pressure c h anges in t h e c h est Wit h t h e pressure c h anges in t h e c h est t h at normally occur wit h breat h ing, airt h at normally occur wit h breat h ing, airmoves in and out of t h e c h est t h roug h t h emoves in and out of t h e c h est t h roug h t h eopening in t h e c h est wallopening in t h e c h est wallLooks bad and sounds worse, but t h eLooks bad and sounds worse, but t h eopening acts as a vent so pressure fromopening acts as a vent so pressure fromtrapped air cannot build up in t h e c h est trapped air cannot build up in t h e c h est

Closed pneumot h oraxClosed pneumot h oraxCh est wall is intact Ch est wall is intact


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Rupture of t h e lung and visceral pleura (or airway)Rupture of t h e lung and visceral pleura (or airway)allows air into t h e pleural spaceallows air into t h e pleural space

In aIn a closed pneumot h oraxclosed pneumot h orax , a patient w h o, a patient w h ois breat h ing spontaneously can h ave anis breat h ing spontaneously can h ave an


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g p yg p y

equilibration of pressures across t h

eequilibration of pressures across t h

ecollapsed lungcollapsed lungTh e patient will h ave symptoms, but t h isTh e patient will h ave symptoms, but t h isis not lifeis not life--t h reateningt h reatening

T ension pneumot h oraxT ension pneumot h orax occurs w h en aoccurs w h en aclosed pneumot h oraxclosed pneumot h orax creates positivecreates positive


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pressure in t h e pleural space t h at pressure in t h e pleural space t h at continues to buildcontinues to buildTh at pressure is t h en transmitted to t h eTh at pressure is t h en transmitted to t h emediastinum ( h eart and great vessels)mediastinum ( h eart and great vessels)

A A tension pneumot h oraxtension pneumot h orax can killcan killCh ll i iCh ll i i


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Ch est wall is intact Ch est wall is intact Air enters t h e pleural space from t h e lung Air enters t h e pleural space from t h e lungor airway, and it h as no way to leaveor airway, and it h as no way to leaveTh ere is no vent to t h e atmosp h ere asTh ere is no vent to t h e atmosp h ere ast h ere is in an open pneumot h oraxt h ere is in an open pneumot h oraxMost dangerous w h en patient is receivingMost dangerous w h en patient is receivingpositive pressure ventilation in w h ich air ispositive pressure ventilation in w h ich air is

forced into t h e c h est under pressureforced into t h e c h est under pressure

MediastinalMediastinal s h ift sh ift occurs w h en t h e pressureoccurs w h en t h e pressuregets so h igh t h at it pus h es t h e h eart andgets so h igh t h at it pus h es t h e h eart and

l i h ff d id fl i h ff d id f


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great vessels into t h e unaffected side of great vessels into t h e unaffected side of t h e c h est t h e c h est Th ese structures are compressed fromTh ese structures are compressed fromexternal pressure and cannot expand toexternal pressure and cannot expand to

accept blood flowaccept blood flow


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MediastinalMediastinal s h ift sh ift can quickly lead tocan quickly lead tocardiovascular collapsecardiovascular collapseTh e vena cava and t h e rig h t side of t h eTh e vena cava and t h e rig h t side of t h eh eart cannot accept venous returnh eart cannot accept venous returnWit h no venous return, t h ere is no cardiacWit h no venous return, t h ere is no cardiacoutput output

No cardiac output = not able to sustainNo cardiac output = not able to sustainlifelife


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Wh en t h e pressure is external, CPR willWh en t h e pressure is external, CPR willnot h elpnot h elp t h e h eart will still not accept t h e h eart will still not accept venous returnvenous return

Immediate, liveImmediate, live- -saving treatment issaving treatment isplacing aplacing a

needle toneedle to relieve pressurerelieve pressure

followed byfollowed by ch

est tubech

est tube


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Blood in the pleural space is a hemothorax


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p p

H emot h oraxH emot h orax occurs after t h oracic surgeryoccurs after t h oracic surgeryand many traumatic injuriesand many traumatic injuries


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As wit h pneumot h orax, t h e negative As wit h pneumot h orax, t h e negativepressure between t h e pleurae is disrupted,pressure between t h e pleurae is disrupted,and t h e lung will collapse to some degree,and t h e lung will collapse to some degree,

depending on t h e amount of blooddepending on t h e amount of blood

Th e risk of Th e risk of mediastinalmediastinal s h ift issh ift isinsignificant, as t h e amount of bloodinsignificant, as t h e amount of bloodneeded to cause t h e s h ift would result in aneeded to cause t h e s h ift would result in alifelife--t h reatening intravascular losst h reatening intravascular loss

H emot h oraxH emot h orax is best seen in an uprig h t is best seen in an uprig h t ch est radiograp hch est radiograp h


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Any accumulation of fluid t h at h ides t h e Any accumulation of fluid t h at h ides t h ecostop h reniccostop h renic angle on an uprig h t CXR isangle on an uprig h t CXR isenoug h to require drainageenoug h to require drainage

Note air/fluid meniscus

Transudate or exudate in the pleural space is apleural effusion


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pleural effusion

Fluid in t h e pleural space isFluid in t h e pleural space is pleuralpleuraleffusioneffusion


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effusioneffusionT ransudateT ransudate is a clear fluid t h at collects in t h eis a clear fluid t h at collects in t h epleural space w h en t h ere are fluid s h ifts in t h epleural space w h en t h ere are fluid s h ifts in t h ebody from conditions suc h as C H F,body from conditions suc h as C H F,malnutrition, renal and liver failuremalnutrition, renal and liver failure

ExudateExudate is a cloudy fluid wit h cells andis a cloudy fluid wit h cells andproteins t h at collects w h en t h e pleurae areproteins t h at collects w h en t h e pleurae are

affected by malignancy or diseases suc h asaffected by malignancy or diseases suc h astuberculosis and pneumoniatuberculosis and pneumonia

T reatment for pleural conditionsT reatment for pleural conditions


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RemoveRemove fluid & air as promptly asfluid & air as promptly aspossiblepossible

Prevent Prevent drained air & fluid fromdrained air & fluid fromreturningreturning to t h e pleural spaceto t h e pleural space

RestoreRestore negative pressure in t h e pleuralnegative pressure in t h e pleuralspace to respace to re- -expand t h e lungexpand t h e lung


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Th oracostomyTh oracostomy creates an opening in t h ecreates an opening in t h ech est wall t h roug h wh ich a c h est tubech est wall t h roug h wh ich a c h est tube(also called t h oracic cat h eter) is placed,(also called t h oracic cat h eter) is placed,

wh ich allows air and fluid to flow out of wh ich allows air and fluid to flow out of t h e c h est t h e c h est

Remove Air and FluidRemove Air and Fluid


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Choose SiteExplore with finger


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Place tube with clamp Suture tube to chest

Th oracic Cat h etersTh oracic Cat h eters


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At t h e end of t h e procedure, t h e surgeon At t h e end of t h e procedure, t h e surgeonmakes a stab wound in t h e c h est wallmakes a stab wound in t h e c h est wallt h roug h wh ich t h e c h est tube is placedt h roug h wh ich t h e c h est tube is placed

into t h e pleural spaceinto t h e pleural space

Prevent air & fluid from returningPrevent air & fluid from returningto pleural spaceto pleural space


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p pp p

Ch est tube is attac h ed to aCh est tube is attac h ed to a drainage devicedrainage device Allows air and fluid to leave t h e c h est Allows air and fluid to leave t h e c h est

Contains a oneContains a one- -way valve to prevent air &way valve to prevent air &fluid returning to t h e c h est fluid returning to t h e c h est Designed so t h at t h e device is below t h e levelDesigned so t h at t h e device is below t h e levelof t h e c h est tube for gravity drainageof t h e c h est tube for gravity drainage

H ow does a c h est drainage system work?H ow does a c h est drainage system work?


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Its all aboutbottles and

straws

Most basic concept Most basic concept Straw attac h ed to c h est tube from patient Straw attac h ed to c h est tube from patient


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pp

is placed under 2cm of fluid (water seal)is placed under 2cm of fluid (water seal)Just like a straw in a drink, air can pus h Just like a straw in a drink, air can pus h t h roug h t h e straw, but air can t be drawnt h roug h t h e straw, but air can t be drawn

back up t h e strawback up t h e straw

Tube open to atmosphere vents air

Tub e from patient

Th is system works if only air is leaving t h eTh is system works if only air is leaving t h ech estch est


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c est c est

If fluid is draining, it will add to t h e fluid inIf fluid is draining, it will add to t h e fluid int h e water seal, and increase t h e dept ht h e water seal, and increase t h e dept h

As t h e dept h increases, it becomes h arder As t h e dept h increases, it becomes h arderfor t h e air to pus h t h roug h a h igh er levelfor t h e air to pus h t h roug h a h igh er levelof water, and could result in air staying inof water, and could result in air staying int h e c h est t h e c h est

For drainage, a second bottle was addedFor drainage, a second bottle was addedTh eTh e first bottlefirst bottle collects t h ecollects t h e drainagedrainageThTh hh


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The

The second bottlesecond bottle is t

heis t

he water sealwater sealWit h an extra bottle for drainage, t h eWit h an extra bottle for drainage, t h e

water seal will t h en remain at 2cmwater seal will t h en remain at 2cm

Tubeopen toatmosphere vents

air

Tub e from patient

Flu id drainage


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Th e twoTh e two--bottle system is t h e key for c h est bottle system is t h e key for c h est drainagedrainage

A place for drainage to collect A place for drainage to collect A one A one--way valve t h at prevents air or fluidway valve t h at prevents air or fluidfrom returning to t h e c h est from returning to t h e c h est

Tube toTube open to

h i


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Tube to

vacuum source

atmosphere vents air

Tube frompatient

Fluid drainage

Th e straw submerged in t h e suctionTh e straw submerged in t h e suctioncontrol bottle (typically to 20cm Hcontrol bottle (typically to 20cm H 22O) limitsO) limitsth e amount of negative pressure t h at canth e amount of negative pressure t h at can


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t e amount of negative pressure t at cant e amount of negative pressure t at canbe applied to t h e pleural spacebe applied to t h e pleural space in t h isin t h iscasecase --20cm H20cm H 22OO

Th e submerged straw is open at t h e topTh e submerged straw is open at t h e top

As t h e vacuum source is increased, once As t h e vacuum source is increased, oncebubbling begins in t h is bottle, it meansbubbling begins in t h is bottle, it meansatmosp h eric pressure is being drawn in toatmosp h eric pressure is being drawn in tolimit t h e suction levellimit t h e suction level

Expiratory positive pressureExpiratory positive pressure from t h efrom t h epatient h elps pus h air and fluid out of t h epatient h elps pus h air and fluid out of t h e

h hh h


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ch

est (cough

,ch

est (cough

, Valsalva Valsalva))

GravityGravity h elps fluid drainage as long as t h eh elps fluid drainage as long as t h e

ch est drainage system is below t h e levelch est drainage system is below t h e levelof t h e c h est of t h e c h est

SuctionSuction can improve t h e speed at w h ich can improve t h e speed at w h ich air and fluid are pulled from t h e c h est air and fluid are pulled from t h e c h est

Th e bottle system worked, but it wasTh e bottle system worked, but it wasbulky at t h e bedside and wit h 1 6 piecesbulky at t h e bedside and wit h 1 6 piecesand 1 7 connections it was difficult to setand 1 7 connections it was difficult to set


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and 1 7 connections, it was difficult to set and 1 7 connections, it was difficult to set up correctly w h ile maintaining sterility of up correctly w h ile maintaining sterility of all of t h e partsall of t h e parts

In 1 967, a oneIn 1 967, a one- -piece, disposable plasticpiece, disposable plasticbox was introducedbox was introduced

Th e box did everyt h ing t h e bottles didTh e box did everyt h ing t h e bottles did and moreand more

To s u ction From patient


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Suctioncontrolbottle

Water sealbottle

Collectionbottle

Su ctioncontrolcham b er

Water sealcham b er

Collectioncham b er

NOTICE THERE IS L OTS OFBUBB L ING IN THE SUCTIONCHAMBER BU T VERY LITT LE INWAT ER S EA L CH AM BE R


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Collection c h amberCollection c h amberFluids drain directly into c h amber calibratedFluids drain directly into c h amber calibrated


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Fluids drain directly into c amber, calibratedFluids drain directly into c amber, calibratedin m L fluid, writein m L fluid, write--on surface to note level andon surface to note level andtimetime

Water sealWater sealOne way valve, UOne way valve, U- -tube design, can monitortube design, can monitorair leaks & c h anges inair leaks & c h anges in intrat h oracicintrat h oracic pressurepressure

Suction control c h amberSuction control c h amberUU--tube, narrow arm is t h e atmosp h eric vent,tube, narrow arm is t h e atmosp h eric vent,

large arm is t h

e fluid reservoir, system islarge arm is t h

e fluid reservoir, system isregulated, easy to control negative pressureregulated, easy to control negative pressure

Keep drain below t h e c h est for gravityKeep drain below t h e c h est for gravitydrainagedrainage


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drainagedrainageTh is will cause aTh is will cause a pressure gradient pressure gradient wit h wit h relatively h igh er pressure in t h e c h est relatively h igh er pressure in t h e c h est Fluid, like air, moves from an area of Fluid, like air, moves from an area of h igh er pressure to an area of lowerh igh er pressure to an area of lowerpressurepressureSame principle as raising an IV bottle toSame principle as raising an IV bottle toincrease flow rateincrease flow rate


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Each time client ex h ales=air is trapped inEach time client ex h ales=air is trapped inhh


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pleural space and it travels down t h

epleural space and it travels down t h

ech est tube to water seal bottle/c h amberch est tube to water seal bottle/c h amberunder water and t h en bubbles up and out under water and t h en bubbles up and out of t h e bottle! Th e water acts as a sealof t h e bottle! Th e water acts as a sealallowing air to escape from pleural spaceallowing air to escape from pleural spacebut preventing air from getting back intobut preventing air from getting back intot h e lungs via negative pressure of t h e lungs via negative pressure of

inspiration!inspiration!

MonitoringMonitoring intrat h oracicintrat h oracic pressurepressure


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Th e water seal c h amber and suction control c h amberTh e water seal c h amber and suction control c h amberprovideprovide intrat h oracicintrat h oracic pressure monitoringpressure monitoringGravity drainage wit h out suctionGravity drainage wit h out suction : Level of water in t h e: Level of water in t h ewater seal c h amber =water seal c h amber = intrat h oracicintrat h oracic pressurepressure (ch amber is(ch amber iscalibrated manometer)calibrated manometer)

Slow, gradual rise in water level over time meansSlow, gradual rise in water level over time meansmore negative pressure in pleural space and signalsmore negative pressure in pleural space and signalsh ealingh ealingGoal is to return toGoal is to return to - -8cm H8cm H 2200

Wit h suctionWit h suction : Level of water in: Level of water in suction control +suction control + level of level of water inwater in water sealwater seal ch amberch amber == intrat h oracicintrat h oracic pressurepressure

Monitoring Air LeakMonitoring Air Leak


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Water seal is a window into t h e pleuralWater seal is a window into t h e pleuralspacespaceNot only for pressureNot only for pressure

If air is leaving t h e c h est,If air is leaving t h e c h est, bubblingbubbling will bewill beseen h ereseen h ere

Air leak meter ( 1 Air leak meter ( 1 --5) provides a way to5) provides a way to

measure t h e leak and monitor over time measure t h e leak and monitor over time getting better or worse?getting better or worse?

Setting up t h e systemSetting up t h e system


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Follow t h e manufacturer s instructions for addingFollow t h e manufacturer s instructions for addingwater to t h e 2cm level in t h e water sealwater to t h e 2cm level in t h e water sealch amber, and to t h e 20cm level in t h e suctionch amber, and to t h e 20cm level in t h e suctioncontrol c h amber (unless a different level iscontrol c h amber (unless a different level isordered)ordered)Connect 6' patient tube to t h oracic cat h eterConnect 6' patient tube to t h oracic cat h eterConnect t h e drain to vacuum, and slowlyConnect t h e drain to vacuum, and slowly

increase vacuum untilincrease vacuum until gentle bubblinggentle bubbling appears inappears int h e suction control c h ambert h e suction control c h amber


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CH EST T UBE MANAGEMENTCH EST T UBE MANAGEMENT

At t h e bedside: Always keep 2 padded clamps At t h e bedside: Always keep 2 padded clamps- - may bemay beneeded if t h e c h est tubes accidentally becomeneeded if t h e c h est tubes accidentally becomedislodged/disconnected from t h e tubing.dislodged/disconnected from t h e tubing.


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PleurPleur--EvacEvac system is t h e new modern closed drainagesystem is t h e new modern closed drainagesystem t h at h as evolved from older 3system t h at h as evolved from older 3- -bottlebottlesystem ..workssystem ..works on same principle:on same principle:

1 =drainage collection bottle ( fluid/blood)1 =drainage collection bottle ( fluid/blood)2= water seal bottle ***** most important 2= water seal bottle ***** most important 3=suction bottle ( only if you need suction) ot h erwise3=suction bottle ( only if you need suction) ot h erwise

suction ch

amber is left open or vented to allow airsuction ch

amber is left open or vented to allow airescape.escape.


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. Make sure all connections are secure. Make sure all connections are secure(use ad h esive tape to prevent a break in(use ad h esive tape to prevent a break int h e system) and sterile petroleumt h e system) and sterile petroleum- - jelly jelly

based occlusive gauze/ dressing arebased occlusive gauze/ dressing areapplied over insertion site to prevent airapplied over insertion site to prevent airleaks!leaks!

Water seal bottle/c h amberWater seal bottle/c h amberTh e water level in t h e water seal bottle/c h amberTh e water level in t h e water seal bottle/c h amber willwillfluctuate gently up and downfluctuate gently up and down wit h eac h wit h eac h


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inspiration/expiration. Th is is calledinspiration/expiration. Th is is called tidalingtidaling

Only timeOnly time tidalingtidaling sh ould stop is 1 .= w h en t h e lung issh ould stop is 1 .= w h en t h e lung is re re--inflated and no longer requires a c h est tube orinflated and no longer requires a c h est tube or

2.= if a problem occurs wit h t h e tubing (kinked,2.= if a problem occurs wit h t h e tubing (kinked,occlusion, breaks in t h e system) and s h ould be c h eckedocclusion, breaks in t h e system) and s h ould be c h ecked

ASAP! ASAP!

3.=If 3.=If constant or vigorous bubbling occur please c h eckconstant or vigorous bubbling occur please c h eckfor a leak somet h ing is wrongfor a leak somet h ing is wrong

Suction bottle/c h amber (bottle #3) used to speedily reSuction bottle/c h amber (bottle #3) used to speedily re- -inflate t h e lungs. Water is added to t h e bottle/c h amber.inflate t h e lungs. Water is added to t h e bottle/c h amber.Suction is applied. (Suction is applied. ( t h e force of suction is solelyt h e force of suction is solelydependent on amount of water in bottle not t h e amount dependent on amount of water in bottle not t h e amount


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ppof suction set on suction mac h ineof suction set on suction mac h ine . If water. If waterevaporatesevaporates=add more water to prescribed level of water.=add more water to prescribed level of water.

See gentle bubbling in suction bottleSee gentle bubbling in suction bottle

If vigorous bubbling=suction will not be maintained; didIf vigorous bubbling=suction will not be maintained; didt h e water evaporate? Add prescribed amount.t h e water evaporate? Add prescribed amount. (DO NOT (DO NOT CONFUSET H IS BUBBLING WIT H T H AT IN T H E WAT ERCONFUSET H IS BUBBLING WIT H T H AT IN T H E WAT ERSEAL CH AMBER)SEAL CH AMBER)

If suction not used: c h amber is t h en left open to allowIf suction not used: c h amber is t h en left open to allowair to escape.air to escape.

Drainage/Collection bottle/c h amber (# 1 )Drainage/Collection bottle/c h amber (# 1 )


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Only used if drain fluid/blood pleural space. (pleuralOnly used if drain fluid/blood pleural space. (pleuraleffusion, c h est trauma, surgery). Drainage c h amber iseffusion, c h est trauma, surgery). Drainage c h amber isnot emptied but just marked amount every s h ift on t h enot emptied but just marked amount every s h ift on t h ebottle/c h amber.bottle/c h amber.

Report any marked increases in bloody drainage/fluid.Report any marked increases in bloody drainage/fluid.Recorded as OutputRecorded as Output

Often w h en c h amber is full; RN/M.D. will c h ange out t h eOften w h en c h amber is full; RN/M.D. will c h ange out t h eclosed c h est drainage system (closed c h est drainage system (PleurPleur--EvacEvac) wit h a new) wit h a newone.one.

General guidelines:General guidelines:

Ch eck system for anyCh eck system for any breaks,cracksbreaks,cracks, kinks in tubing, or, kinks in tubing, orbroken connectionsbroken connections


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Auscultate lung sounds, any sudden SOB, dyspnea, Auscultate lung sounds, any sudden SOB, dyspnea,pain, h ear any pain, h ear any crepitouscrepitous sounds= t h ink SQsounds= t h ink SQemp h ysema? h ear & palpate for leakage of air into SQemp h ysema? h ear & palpate for leakage of air into SQtissuetissueT igh t occlusive dressing intact? Clamps at bedside?T igh t occlusive dressing intact? Clamps at bedside?No dependent loops tubing? Is t h e drainage systemNo dependent loops tubing? Is t h e drainage systembelow c h est level?below c h est level?Ch eck water seal c h amber and or suction c h amber forCh eck water seal c h amber and or suction c h amber fort h e correct amount of water in c h ambers? Any vigoroust h e correct amount of water in c h ambers? Any vigorous

bubbling? leaks?bubbling? leaks?Record drainage as output Record drainage as output

If client must be transported: suction is usually off andIf client must be transported: suction is usually off andair is vented out. T ubing is not clamped for transport!air is vented out. T ubing is not clamped for transport!

If a tube accidentally pulls out=quickly place a tig h t If a tube accidentally pulls out=quickly place a tig h t


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occlusive dressing over t h e insertion site on t h e c h est toocclusive dressing over t h e insertion site on t h e c h est toprevent air from reprevent air from re- -entering follow h ospital policyentering follow h ospital policy

Process of Milking and Stripping tubes isProcess of Milking and Stripping tubes iscontroversial follow h ospital policycontroversial follow h ospital policy

If time to D/If time to D/C dC d t h e Ch est tube/closed drainage system=t h e Ch est tube/closed drainage system=M.D. pulls tube out and tig h t occlusive petroleumM.D. pulls tube out and tig h t occlusive petroleum- -jelly jellybased gauze is applied over insertion site: CXR donebased gauze is applied over insertion site: CXR done

(ch

eck for pneumot h

orax d/t a puncture lung?), Monitor(ch

eck for pneumot h

orax d/t a puncture lung?), Monitorrespirations & forrespirations & for crepitouscrepitous??


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resp.system rosemary

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