MV Chapter 14
Since clotting of the chest tube with blood or pleural fluid is less likely in pneumothoraces
16 to 20 Fr may be adequate for adults
For children and neonates
18 and 12 to 14 Fr, respectively
For small adults or teens
28 to 32 Fr
chest tube size for large adults
36 to 40 French
The projected total time of transport should be a factor in deciding which mode of transportation to use.
A ground ambulance or helicopter may be used for patient transport when the distance is less than 150 miles.
The chest tube can be removed when the pleural drainage has stopped or slowed to less than 100 mL over the preceding 24 hours, or when the pneumothorax has resolved and there is no further air leak.
Air leak (bubbling in the middle chamber) may be tested by asking the patient to perform a Valsalva's maneuver or a forceful cough
Diagnostic bronchoscopy is done to gather additional information or to confirm preliminary diagnosis following history, physical, and other laboratory results
An example of diagnostic bronchoscopy is the evaluation of tumors in the airways and lungs, airway obstruction, hemoptysis, inflammation and infection, interstitial pulmonary disease, staging of lung cancer before surgery, vocal cord paralysis, and tissue or fluid samples collected from the airways or lungs.
fiberoptic bronchoscope
An instrument that uses glass fibers to transmit images of the airway for diagnostic or therapeutic procedures under direct vision
For intrahospital transport of mechanically ventilated patients, a transport ventilator is preferable to manual ventilation.
In pressure control mode, the expired volume must be monitored closely. Decreasing compliance or increasing airflow resistance can lead to decreasing tidal volume.
During chest tube placement, the point of entry is directly over the body of the rib to avoid complications
Incisions or punctures are done above the rib because arteries, veins, and intercostal nerves all lie below each rib.
Complications of bronchoscopy include infection, hypoxemia, hemorrhage, and pneumothorax.
Infection-There were reports of transmission and outbreak of Mycobacterium tuberculosis and Pseudomonas aeruginosa infections caused by the flexible bronchoscope.
In operative tube thoracostomy, the incision is made parallel to and above the rib
It is followed by blunt dissection into the pleura. A finger is inserted into the opening for inspection of the pleural space.
Bleeding can occur during bronchoscopy
Most minor bleeding may be stopped by saline lavage
Lidocaine, atropine sulfate, morphine sulfate, and diazepam are four common medications for bronchoscopy.
Once the insertion tube enters the trachea and reaches above the carina, the tube is directed to the intended bronchi and segments
Hypoxemia and arrhythmias are the most common complications during and after bronchoscopy.
Oxygen therapy, proper use of topical anesthesia, and use of intermittent suction are useful techniques to minimize the occurrence of these complications. Continuous pulse oximeter should be used during the recovery period.
Secretion Collection
Pulmonary secretions are sometimes required for microscopic, culture and sensitivity, or cytology studies
If wedging cannot be done because the airway is larger than the distal end of the bronchoscope, a 6-Fr Fogarty embolectomy catheter with balloon tip may be inserted through the channel.
Puncture of the lung while the patient is receiving mechanical ventilation may lead to tension pneumothorax
Helicopters are preferable when the traffic or terrain condition precludes a timely arrival at the destination by ground ambulances. Of course, both facilities must have a suitable landing site for helicopters.
Sometimes a propeller-driven aircraft is used for a distance between 100 and 200 miles.
Bronchial Brushing
The brush is then withdrawn into the shield and the entire apparatus is removed from the channel outlet of the bronchoscope. A microscopic slide may be made by fixing it with a suitable solution. An alternative is to cut off the brush and send it for pathologic tests.
Therapeutic bronchoscopy may be used as a treatment modality because of the small size and versatility of the flexible bronchoscope.
The general indications for therapeutic bronchoscopy include removal of retained secretions, mucus plugs, or polyps in the airway, (2 removal of foreign bodies (common in pediatric patients), removal of endobronchial tissues, intubation of difficult airway, and drainage of an abscess. Large foreign objects in the airway are removed by rigid bronchoscope.
For drainage of blood or other pleural fluids, a size 36 Fr (ranging from 28 to 40 Fr) chest tube is recommended to reduce clotting
The insertion point is from the fourth to sixth intercostal space at the midaxillary line (usually a line lateral to the nipple) for optimal drainage of pleural fluid
If a large amount of bubbling is observed in the middle chamber, air leak in the drainage system or presence of air in the pleural space may be the cause.
The patient, connections, vacuum level, and amount of sterile water in the drainage unit should be checked for the source of air leaks.
Tissue specimens are obtained by passing the biopsy forceps through the biopsy channel outlet
The razor-sharp biopsy device at the distal end of the forceps can be opened and closed by the operator using the control handle. The tissue specimen collected by the forceps is retrieved and put in a formalin solution for laboratory analysis.
Three-Chamber System
The water level in chamber 3 (suction chamber) regulates the amount of suction in the three-chamber system.
Since chamber 1 collects all pleural fluid, the submersion depth of the long tube in chamber 2 remains unchanged.
The work of spontaneous breathing is therefore unaffected by the volume of pleural fluid collected in this chamber.
The short air-vent tube prevents pressure buildup in the chamber. The long tube is submerged in exactly 2 cm of water.
This acts as a water seal which allows air to escape but not to return.
The water level in the middle (water seal) chamber normally fluctuates with respiration
This means the tube and drainage system are working properly
The chest tube is clamped with forceps before complete withdrawal of the trocar.
This method requires a smaller incision and provides less tissue trauma and less patient discomfort
bronchial brushing:
Tissue or loosened cell specimens collected by a shielded small brush using a brushing motion.
Transbronchial Needle Aspiration Biopsy.
Tissue specimens collected by applying aspiration while moving the needle at the sample collection site.
Transbronchial Lung Biopsy
Tissue specimens collected by the forceps during a forced exhalation maneuver. necessary to obtain a definitive diagnosis based on preliminary radiographic findings.
Under normal working condition, the vacuum draws air into the fluid through the venting tube in chamber 3, causing a constant slow bubbling effect.
Too much bubbling means the vacuum level is set too high.
Small "E" size oxygen cylinders with wrench must be full. In the event of delay, the oxygen content should be at least twice the volume needed for a one-way transport
Transport equipment coming near the MRI scanner must be resistant to the magnetic field produced by the scanner. only aluminum oxygen cylinders should be used
For distances greater than 200 miles or intercontinental transport, a jet is preferred.
Use of a jet is typically done for nonemergency cases since a jet involves more resources and higher costs
The bronchoscope decreases the size of the airway opening and may cause partial airflow obstruction
Ventilation/perfusion (V/Q) mismatch and secondary hypoxemia may occur during and after bronchoscopy because of the retained lavage solution, hypoventilation from premedication, mobilized and pooled secretions, and excessive suctioning.
A trocar is
a sharply pointed instrument for incision into the chest cavity
Operative tube thoracostomy and trocar tube thoracostomy are
common methods to perform chest tube placement.
This method is safer than trocar tube thoracostomy because
digital inspection eliminates the possibility of chest tube placement between the parietal pleura and the chest wall.
Potential complications of chest tube placement include
hemorrhage at the insertion site, hematoma, and laceration of lung parenchyma or intra-abdominal organs. Infection can be a late complication
Relative contraindications include
infection over the insertion site, and conditions that may lead to severe bleeding during chest tube placement
transport ventilator: A mechanical ventilator capable of operation without piped-in gas sources or electrical connection.
interhospital transport: Moving a patient between two hospitals.
Iatrogenic pneumothorax may be caused by
invasive procedures such as thoracentesis, central vein/pulmonary artery catheterization, and bronchoscopy/transbronchial biopsy
Transbronchial Needle Aspiration Biopsy.
is done by pressing the tip of the bronchoscope gently against the target puncture site.
Transbronchial Needle Aspiration Biopsy
is done where the lesion is located beyond the bronchial wall and there is no lesion in the bronchial lumen.
Forceps Biopsy
is done within the visual range of the bronchoscope.
Common indications for chest tube include
large pneumothorax (>25%), hemothorax, and pleural effusion
As pleural fluid drains and accumulates in the chamber
more of the long tube is submerged and spontaneous breathing becomes more difficult.
The chest tube/trocar setup should enter the chest only 1 to 2 cm
otherwise puncture of the lung is likely.
Causes of pneumothorax include
positive pressure ventilation, ruptured bleb due to emphysema, bronchopleural fistula, leaking subpleural cyst, and chest trauma.
To treat pneumothorax, the chest tube (16 to 20 Fr) is usually placed at the
second or third intercostal space anteriorly along the midclavicular line or midaxillary line.
Four modes of transportation are available: ground ambulance, helicopter, propeller-drive aircraft, and jet
short time (e.g., less than 30 min), manual ventilation with a resuscitation bag and oxygen may be sufficient.
The chest tube may be
straight, curved, trocar, or nontrocar.
Since the flange has a narrow diameter, any clots from the pleural cavity may become lodged at this location.
tape should not interfere with the visual inspection of any clot formation inside the connector.
In a one-chamber water-seal system
the chamber initially contains 100 mL of sterile water.
Once inside the pleural space,
the chest tube is advanced over the trocar—a procedure similar to the "catheter over needle" technique for artery line placement.
a clamped chest tube may potentially convert a simple pleural air leak to life-threatening tension pneumothorax.
the chest tube must be unobstructed and connected to a functional water seal drainage system. The water seal allows air or fluid to exit the pleural space and prevents it from being drawn back into the pleural space
In trocar tube thoracostomy,
the incision is also made parallel to and above the rib.
Following placement,
the rigid chest tube is connected to the flexible Creech tubing with a clear, ridged plastic connector flange.
The most common and versatile drainage system in the hospital is
the threechamber setup such as Pleur-Evac. It requires a vacuum. unusual occurrence with the drainage system must be correlated to the patient's condition and vital signs.
Excessive pleural fluid may be caused by
thoracic trauma (hemothorax), heart failure (pleural effusion), intra-abdominal infection (empyema), and blockage of lymphatic system (chylothorax)
A chest tube is then guided into the pleural space by
using a finger and hemostat or Kelly clamp
If the chest tube is disconnected from the drainage unit, clamp the chest tube and reconnect it with a new drainage unit
Clamping of the chest tube should not exceed 1 min
For safety reasons, transport of mechanically ventilated patients must follow a thorough evaluation of the risk-benefit factor based on the patient's clinical condition.
Contraindications for transport of mechanically ventilated patients include inability to provide adequate oxygenation and ventilation, inability to maintain acceptable hemodynamic status, inability to provide adequate airway control or cardiopulmonary monitoring, and lack of trained transport team members. A patient should not be transported when the hemodynamic status is deteriorating or unstable.
The suture is first removed and the patient is instructed to perform a Valsalva's maneuver right before pulling out the chest tube
Follow-up chest radiography is done in 4 hours to allow proper lung re-expansion and to detect reoccurring pneumothorax
Transport----The plan should include the transport team procedure, and equipment and supplies necessary for a safe and uncomplicated transport.
For interhospital ground or air transport, it is usually done to acquire tertiary medical care or procedures (e.g., burn care, third-level nursery) that are only available at the destination facility
Clotting of blood inside the chest tube is a potential complication following placement.
For this reason, larger tubes are selected for treatment of hemothorax or other thick pleural fluids (e.g., empyema).
The level of suction applied to the pleural space is determined by the submersion depth of the venting tube in suction chamber 3.
For this reason, the water level in suction chamber 3 must be monitored and kept at the appropriate level in order to maintain a desired vacuum level (from 210 to 220 cm H2O).
Minor air leak may be compensated by increasing the tidal volume. The pressure limit may need to be increased to make allowance for a larger tidal volume and insertion tube in the endotracheal tube
Hypoxia and increase in peak inspiratory pressure are common when bronchoscopy is done on patients receiving mechanical ventilation.
For patients who are breathing spontaneously and without an artificial airway, oxygen therapy of up to 6 L/min may be given.
If the bronchoscope insertion tube is inserted via an artificial airway (endotracheal or tracheostomy tube), an aerosol setup may be used. Adequate SpO2 may be titrated with a pulse oximeter.
If the drainage holes on the chest tube become visible, the physician should be notified immediately for repositioning or reinsertion.
If the chest tube becomes disconnected from the patient, an occlusive dressing such as Vaseline gauze should immediately be applied over the incision opening.
The chest tube should be kept in a straight line as much as possible.
If the tube is looped or kinked, the suction level will decrease and lung re-expansion may be hindered. In addition, fluid in the tube may re-enter the pleural space, leading to the possibility of infection.
Some bubbling from the long tube is normal as long as there is air in the pleural space.
If there is no bubbling, either there is an obstruction or there is no more air in the pleural space
The two-chamber drainage system uses chamber 1 to collect drainage or pleural fluid or evacuate pleural air. The amount of pleural drainage can be measured from chamber 1
In chamber 2, the short tube allows air to escape and prevents pressure to build up. The long tube in chamber 2 is submerged in 2 cm of water as in the one-chamber drainage system
Supplemental oxygen should be used to alleviate the problem of secondary oxygen desaturation during bronchoscopy
In most cases, oxygen therapy may be discontinued 4 hours after bronchoscopy
Worsening cyanosis in spite of high oxygen concentration, diaphoresis, tachypnea, tachycardia, and thready pulse are some signs of tension pneumothorax.
Chest tube is the treatment for tension pneumothorax and a complete chest tube setup should be on the bronchoscopy supplies list.
When substantial bleeding occurs, a vasopressor (e.g., 1 mL of 1:1000 epinephrine with 9 mL of normal saline given in 2-mL portions) can be used to control bleeding from the biopsy site.
Bleeding may also be stopped by wedging the bleeding site with the distal end of the bronchoscope.
Three-Chamber System
Chamber 1 (collection chamber) collects the pleural fluid from the patient.
Three-Chamber System
Chamber 2 (water seal chamber) has about 2 cm of water in it and functions as a water seal.
In addition to an oxygen source, primary emergency drugs and airway equipment should be available during transport.
During transport, the drainage system must be kept lower than the patient's chest and the chest tube must not be clamped or occluded.
If sudden deterioration of the patient's condition occurs, chest radiography should be taken to rule out pneumothorax.
Ethylene oxide is used to sterilize delicate parts that cannot withstand steam autoclave
