Dr. Navdeep Singh Junior resident Pulmonary medicine
Slide 3
DEFINITION A chest drain is a tube inserted through the chest
wall between the ribs and into the pleural cavity to allow drainage
of air (pneumothorax), blood (haemothorax), fluid (pleural
effusion) or pus (empyema) out of the chest. This allows drainage
of the pleural contents and re- expansion of the lung. In the case
of a pneumothorax or haemothorax this helps restore haemodynamic
and respiratory stability by optimising ventilation/perfusion and
minimizing mediastinal shift.
Slide 4
INDICATIONS OF ITS USE Pneumothorax not all pneumothoraces
require insertion of a chest drain. Primary spontaneous
pneumothorax :Patients with underlying lung disease and traumatic
pneumothoraces usually require chest drainage. The differential
diagnosis between a pneumothorax and bullous disease requires
careful radiological assessment persistent or recurrent
pneumothorax after simple aspiration tension pneumothorax should
always be treated with a chest drain after initial relief with a
small bore cannula or needle in any ventilated patient with a
pneumothorax as the positive airway pressure will force air into
the pleural cavity and quickly produce a tension pneumothorax large
secondary spontaneous pneumothorax in patients over 50 years of age
iatrogenic eg.following insertion of a central venous catheter. Not
all will require drainage.
Slide 5
Pleural effusion Pleural fluid Malignant pleural effusion
Simple pleural effusions in ventilated patients Empyema and
complicated parapneumonic pleural effusion Traumatic pneumothorax
or haemopneumothorax Peri-operative eg. thoracotomy, oesophageal
surgery, cardiothoracic surgery
Slide 6
Insertion of a chest drain Before insertion of the chest drain:
Consent Consent should be obtained and documented as per Trust
guidance. The identity of the patient should be checked and the
site and insertion of the chest drain confirmed by reviewing the
clinical signs and the radiological information.
Slide 7
PRE-DRAINAGE RISK ASSESSMENT Risk of haemorrhage: where
possible, any coagulopathy or platelet defect should be corrected
prior to chest drain insertion but routine measurement of the
platelet count and prothrombin time are only recommended in
patients with known risk factors. The differential diagnosis
between a pneumothorax and bullous disease requires careful
radiological assessment. Similarly it is important to differentiate
between the presence of collapse and a pleural effusion when the
chest radiograph shows a unilateral whiteout. Lung densely adherent
to the chest wall throughout the hemithorax is an absolute
contraindication to chest drain insertion. The drainage of a post
pneumonectomy space should only be carried out by or after
consultation with a cardiothoracic surgeon.
Slide 8
EQUIPMENT Equipment required for insertion of chest drains.
Sterile gloves and gown Skin antiseptic solution, e.g. iodine or
chlorhexidine in alcohol Sterile drapes Gauze swabs A selection of
syringes and needles (2125 gauge) Local anaesthetic, e.g.
lignocaine (lidocaine) 1% or 2% Scalpel and blade Suture (e.g. 1
silk) Instrument for blunt dissection (e.g. curved clamp) Guidewire
with dilators (if small tube being used) Chest tube Connecting
tubing Closed drainage system (including sterile water if
underwater seal being used) Dressing Equipment may also be
available in kit form.
Slide 9
CONSENT AND PREMEDICATION Unless there are contraindications to
its use, premedication (benzodiazepine or opioid) should be given
to reduce patient distress. Premedication could be an intravenous
anxiolyticfor example, midazolam 15 mg titrated to achieve adequate
sedationgiven immediately before the procedure or an intramuscular
opioid given 1 hour before, although neither drug has e clearly
superior.
Slide 10
PATIENT POSITION The preferred position for drain insertion is
on the bed, slightly rotated, with the arm on the side of the
lesion behind the patients head to expose the axillary area. An
alternative is for the patient to sit upright leaning over an
adjacent table with a pillow or in the lateral decubitus position.
Insertion should be in the safe triangle
Slide 11
CONFIRMING SITE OF DRAIN INSERTION A chest tube should not be
inserted without further image guidance if free air or fluid cannot
be aspirated with a needle at the time of anaesthesia. Imaging
should be used to select the appropriate site for chest tube
placement. Fluoroscopy, ultrasonography, and CT scanning can all be
used as adjunctive guides to the site of tube placement.Before
insertion, air or fluid should be aspirated; if none is
forthcoming, more complex imaging than a chest radiograph is
required.
Slide 12
The use of ultrasonography guided insertion is particularly
useful for empyema and effusions as the diaphragm can be localised
and the presence of loculations and pleural thickening defined.
Using real time scanning at the time of the procedure can help to
ensure that the placement is safe despite the movement of the
diaphragm during respiration. The complication rate following image
guided thoracocentesis is low with pneumothoraces occurring in
approximately 3% of cases. Success rates of image guided chest tube
insertion are reported to be 7186%.
Slide 13
TRIANGLE OF SAFETY ANTERIOR: LATERAL BORDER OF PECTORALIS
MAJOR. LATERAL: LATERAL BORDER OF LATTISMUS DORSI/MID-AXILLARY
LINE. INFERIOR: LINE IN 5 TH INTERCOSTAL SPACE/ IMAGINARY
HORIZONTAL LINE FROM NIPPLE. SUPERIOR: BASE OF AXILLA.
SIGNIFICANCE:MINIMIZE THE RISK OF INJURY,BLOOD VESSEL,MUSCLES,HEART
TISSUE AND INTERNAL MAMMARY ARTERY AND DECRREASED SCARING
Slide 14
Insertion site Fourth or fifth intercostal space in the
anterior axillary or mid-axillary line. Second intercostal space in
the mid-clavicular line alternate site dissection through the
pectoralis muscle leaves a visible scar loculated anterior
pneumothorax with the use of a small bore catheter (10 to 14 Fr)
rather than a standard chest tube.
Slide 15
DRAIN SIZE Chest drains come in a range of sizes suitable for a
variety of purposes (typically 10-36Ch) and may be inserted via an
open surgical incision (thoracostomy) or using the Seldinger
technique incorporating a guide wire and dilator system. The
following chest drain tube sizes are available for use in adult
patients within the Trust 12Ch 18 Ch 20Ch 28Ch 32Ch
Slide 16
Specific Considerations How to choose a chest tube size?
Pneumothorax A 16 to 24 Fr chest tube. Traumatic pneumothorax 28 to
40 Fr chest tube drainage of blood in addition to air may be
necessary. Malignant effusion A 20 to 24 Fr chest tube Empyema 28
to 36 Fr chest tube May need more than one tube for loculated areas
Hemothorax 32 to 40 Fr chest Larger caliber helps prevent
occlusion
Slide 17
Insertion of a small bore drain under image guidance with a
guidewire does not require blunt dissection. These have been
successfully used for pneumothorax, effusions, or loculated
empyemas. Medium bore tube (1624 F) Large bore tube (>24F):
Large bore drains are recommended for drainage of acute haemothorax
to monitor further blood loss. The use of large bore drains has
previously been recommended as it was felt that there was an
increase in the frequency of drain blockage, particularly by thick
malignant or infected fluid. The majority of physicians now use
smaller catheters (1014 French (F)) and studies have shown that
these are often as effective as larger bore tubes and are more
comfortable and better tolerated by the patient
Slide 18
The use of small bore pigtail catheters has allowed outpatient
treatment of malignant pleural effusions which have not responded
to chemotherapy. Empyemas are often successfully drained with
ultrasonically placed small bore tubes with the aid of thrombolytic
agents. In the case of acute haemothorax, however, large bore tubes
(2830 F minimum) continue to be recommended for their dual role of
drainage of the thoracic cavity and assessment of continuing blood
loss.
Slide 19
ASEPTIC TECHNIQUE Aseptic technique should be employed during
catheter insertion. Prophylactic antibiotics should be given in
trauma cases.
Slide 20
ANAESTHESIA Local anaesthetic should be infiltrated prior to
insertion of the drain. Local anaesthetic is infiltrated into the
site of insertion of the drain. A small gauge needle is used to
raise a dermal bleb before deeper infiltration of the intercostal
muscles and pleural surface. Local anaesthetic such as lignocaine
(up to 3 mg/kg ) is usually infiltrated.
Slide 21
Chest Tube Insertion chest tubes are inserted into the pleural
space by four methods: 1. Tube thoracostomy with a guidewire and
dilators. 2. Tube thoracostomy with a trocar. 3. Operative tube
thoracostomy. 4. Tube thoracoscopy through a single-port
thoracoscope
Slide 22
Operative Tube Thoracostomy It is important to emphasize that
operative tube thoracotomy can be very painful. Therefore, it is
recommended that patients be given a narcotic or an anxiolytic
medication 10 to 15 minutes before the procedure and that liberal
doses of local anesthetic be used. To perform an operative tube
thoracostomy, a 3- to 4- cm incision is made in the skin parallel
to the chosen intercostal space. The incision should be made down
to the fascia overlying the intercostal muscle. This fascia is then
incised throughout the length of the incision, with care taken not
to cut the muscle.
Slide 23
Once the fascia has been incised, the muscle fibers are spread
with a blunt-tipped hemostat until the intercostal interspace is
identified. Then, an incision is made in the intercostal fascia
just above the superior border of the inferior rib over which the
tube will pass. The parietal pleura is then penetrated by pushing a
blunt-tipped hemostat through it. The hole in the parietal pleura
is then enlarged by means of the operator's index finger. At this
time, the operator should palpate the adjacent pleural space to
detect any adhesions. Then, the chest tube with its distal end
clamped is inserted into the pleural space. A hemostat is used to
guide the tube into the pleural space as the operator's finger is
withdrawn
Slide 24
Operative tube thoracostomy. A: The physician's index finger is
used to enlarge the opening and to explore the pleural space. B:
Placement of chest tube intrapleurally using a large hemostat.
Slide 25
Slide 26
Single-Port Thoracoscopy A rod-lens telescope was placed into
the most proximal port of a 28 F chest tube. Then under direct
visualization, the chest tube was placed into the
costodiaphragmatic gutter and the telescope was removed. A flexible
pleuroscope should not be used because of its larger diameter and
potential for damage to the distal flexible portion of the scope
when placed or removed from within the chest tube.
Slide 27
Slide 28
Guidewire tube thoracostomy. A: Making a small skin incision
slightly larger than the diameter of the chest tube. B:
Introduction of 18-gauge needle into the pleural space. C:
Insertion of wire with end into the pleural space. D: With
guidewire in place, the tract is enlarged by advancing
progressively larger dilators over the wire guide. Introduction of
the dilators is facilitated by rotating and advancing the dilators
in the same plane of the wire guide. E: Introduction of the chest
tube inserter or chest tube assembly over the guidewire. F: The
guidewire and the chest tube inserter have been removed, leaving
the chest tube positioned within the pleural space.
Slide 29
Trocar Tube Thoracostomy A: Insertion of trocar into the
pleural space. Note the position of the hands, the position of the
trocar relative to the ribs, and the cephalad position of the flat
edge of the trocar. B: Insertion of chest tube through the
trocar.
Slide 30
COMPLICATIONS The most serious complications of tube
thoracostomy are insertion of the tube ectopically, namely, into
the lung, stomach, spleen, liver, or heart. These complications are
more likely when a trocar chest tube is used. With the operative
method, digital exploration of the insertion site delineates
whether the tract leads into the pleural space and whether any
tissue or organ is adherent to the parietal pleura at the planned
site of tube insertion.
Slide 31
Verification of Chest Tube Placement After the chest tube has
been inserted and connected to a drainage system, a chest
radiograph should be obtained to verify the correctness of its
position. Ideally, both a posteroanterior (PA) and a lateral view
should be obtained, because certain ectopic locations may not be
apparent on the PA view alone. A CT scan should be obtained when
the chest tube does not drain adequately and the chest radiograph
is noncontributory.
Slide 32
Draining systems: Prevent air & fluid from returning to the
pleural space Most basic concept Straw attached to chest tube from
patient is placed under 2cm of fluid (water seal) Just like a straw
in a drink, air can push through the straw, but air cant be drawn
back up the straw Tube open to atmosphere vents air Tube from
patient
Slide 33
When the pleural pressure is positive, the pressure in the
rigid straw becomes positive, and if the pressure inside the rigid
straw is greater than the depth to which the straw is inserted into
the saline solution, air (or liquid) will enter the bottle and will
be vented to the atmosphere (or collect in the bottle). If the
pleural pressure is negative, fluid will be drawn from the bottle
into the rigid straw and no extra air will enter the system of the
pleural space and the rigid straw. This system is called a water
seal because the water in the bottle seals the pleural space from
air or fluid from outside the body.
Slide 34
Prevent air & fluid from returning to the pleural space
This system works if only air is leaving the chest If fluid is
draining, it will add to the fluid in the water seal, and increase
the depth As the depth increases, it becomes harder for the air to
push through a higher level of water, and could result in air
staying in the chest
Slide 35
Prevent air & fluid from returning to the pleural space For
drainage, a second bottle was added The first bottle collects the
drainage The second bottle is the water seal With an extra bottle
for drainage, the water seal will then remain at 2cm Tube from
patient Tube open to atmosphere vents air Fluid drainage 2cm
fluid
Slide 36
With this system, the bottle adjacent to the patient acts as a
collection bottle for the drainage, and the second bottle provides
the water seal and the air vent. Therefore, the degree of water
seal does not increase as the drainage accumulates. The water-seal
bottle functions identically in both the one and two-bottle
systems.
Slide 37
Restore negative pressure in the pleural space 2cm fluid water
sealCollection bottleSuction control Tube from patient Fluid
drainage Tube open to atmosphere vents air Straw under 20 cmH 2 O
Tube to vacuum source
Slide 38
It is desirable to apply negative pressure to the pleural space
to facilitate reexpansion of the underlying lung or to expedite the
removal of air or fluid from the pleural space. Suction at a fixed
level, usually -15 to -20 cm H 2 O, can be applied to the vent on a
one- or two-bottle collection system with an Emerson pump.
Three-bottle systems are unwieldy to set up and are cumbersome to
move if the patient needs to be transported.
Slide 39
Following insertion of the chest drain it is essential to :-
check the underwater seal oscillates during respiration order a
repeat chest x-ray to confirm the position of the tube and the
degree of lung re-expansion and exclude any complication advise the
patient to keep the underwater bottle below the drain insertion
site,` upright and avoid compressing the tube by sitting or lying
on it ensure regular analgesia is prescribed whilst the chest drain
is in place
Slide 40
Commercially Available Drainage Systems An acceptable drainage
system should have the following characteristics: (a) the water
seal should be easily visualized, so one can determine whether the
chest tube is patent and whether an air leak is present. Some
systems have a one-way valve that does not contain water, but one
can (and should, if dealing with a pneumothorax) fill the chamber
with water to view the bubbling. (b) the tube should be functional
when no suction is applied. (c) the volume of the collection
chamber should be adequate and the markings should be such that the
drainage is easily quantitated. (d) there should be a pop-off valve
to provide a safety factor if pressure builds up in the
system.
Slide 41
Pleur-Evac Unit Pleur-Evac collection system, which is
analogous to a three-bottle collection system. The area labeled C
is the calibrated collection system; W is the water-seal chamber; S
is the suction-control chamber. Arrows demonstrate the pathway for
air to leave the pleural space. If the suction vent is left open to
atmospheric pressure, the Pleur-Evac system functions as a
two-bottle collection system. When suction is applied, atmospheric
air enters through S and leaves through the suction apparatus.
Slide 42
Slide 43
Care of a Chest Tube Is there bubbling through the water-seal
bottle or the water-seal chamber on the disposable unit? Is the
tube functioning? What is the amount and type of drainage from the
tube?
Slide 44
Bubbling through Water-Seal Chamber If the patient is receiving
water-seal drainage without suction, the presence of bubbling in
the water seal usually indicates a persistent air leak from the
lung into the pleural space. If no air bubbles are seen on the
initial inspection of the water seal, the patient should be asked
to cough, and the water seal should be observed for bubbling. The
coughing maneuver increases the patient's pleural pressure and
should demonstrate small air leaks into the pleural space. If the
patient is receiving suction, disconnection or partial
disconnection anywhere between the water seal and the patient will
lead to bubbling through the water seal
Slide 45
Leaks in the system may be detected by clamping the chest tube
at the point where it exits from the chest. If bubbling through the
water seal persists, the drainage system itself is responsible for
the leak, and it should be examined thoroughly for leaks. If the
bubbling stops when the chest tube is clamped, then the air is
coming from the pleural space. The presence of bubbling through the
water seal does not necessarily indicate a communication between
the lung and the pleural space. If the chest tube is not inserted
far enough into the pleural space, one or more of the holes in the
chest tube may lie outside the pleural space.
Slide 46
Patients with poor tissue turgor, the negative pleural pressure
will cause air to enter the pleural space around the chest tube at
the insertion site. At times it may be difficult to tell whether
the air is leaking around the chest tube or whether it is due to a
bronchopleural fistula. One may make this differentiation by
measuring the level of PCO 2 in the air coming from the chest
tube.
Slide 47
Is the Chest Tube Functioning? If the patient is not receiving
suction, one should observe the level of the liquid in the water
seal. If the chest tube is patent and in the pleural space, the
level of the liquid should move higher on inspiration in the limb
of the water seal proximal to the patient, indicating a more
negative pleural pressure. Of course, if the patient is receiving
mechanical ventilation, the level of liquid in the proximal limb
will go down on inspiration because the pleural pressure becomes
more positive. When no fluctuations are observed synchronous with
respiratory movements, the patient should be asked to make a
maximal inspiratory effort, and if still no movement is observed,
it indicates that the chest tube is not functioning. If a chest
tube is not functioning, its functional status should be restored,
or it should be removed. Chest tubes can become obstructed with
tissue around the holes or by clots within the tube. The simplest
method for restoring patency is to flush the tube with 50 mL of
saline.
Slide 48
Amount and Type of Drainage The amount and the character of the
drainage from the chest tube should be recorded for each 24-hour
period. The amount of drainage is most easily quantitated by
marking the level of the liquid in the collection chamber each day.
This record-keeping is important because many therapeutic decisions
based on the quantity of the drainage. The character of the
drainage is best described by quantitating the percentage of solid
drainage material. This quantitation is easily done by marking the
level of the sediment in the collection chamber each day. If the
increase in volume of the entire collection system is known and if
the increase in volume of the solid sediment is known, it is simple
to calculate what percentage of the daily drainage is solid.
Slide 49
Monitoring/recording The frequency of observations depends on
clinical presentation/progress and medical request but should
happen at least 4 hourly. Fluid within the tube should swing with
respiration due to changes in intrapleural pressure. With normal
respiration, the fluid should rise on inspiration and fall on
expiration. Absence of swinging indicates that the drain is
occluded or is no longer in the pleural space. It may be necessary
following clinical assessment and unsuccessful flushing of the
drain to obtain a chest x- ray to determine the underlying
cause.
Slide 50
A drain inserted for drainage of a haemothorax (+/-
pneumothorax) needs blood loss to be recorded accurately with any
sudden increases in drain volume referred immediately for medical
review. With fractured ribs most bleeding is from the intercostal
vessels, which slows down as the lung reinflates. However continued
bleeding into the drain bottle is indicative of pathology that may
need thoracic surgical intervention. After thoracic trauma more
than 1500ml of blood into the bottle initially or continued
bleeding of greater than 200ml/hr requires discussion with the
thoracic surgeons.
Slide 51
When to clamp? Clamping drain A bubbling chest tube should
never be clamped. Drainage of a large pleural effusion should be
controlled to prevent the potential complication of re- expansion
pulmonary oedema. In cases of pneumothorax, clamping of the chest
tube should usually be avoided. If a chest tube for pneumothorax is
clamped, this should be under the supervision of a respiratory
physician or thoracic surgeon, the patient should be managed in a
specialist ward with experienced nursing staff, and the patient
should not leave the ward environment. If a patient with a clamped
drain becomes breathless or develops subcutaneous emphysema, the
drain must be immediately unclamped and medical advice sought.
Slide 52
Changing the drain bottle When changing the drain bottle
because it is overfull, temporary clamping of the drainage tube may
be necessary to prevent ingress of air into the pleural cavity. It
is acceptable to clamp the tube between thumb and forefinger. This
has the advantage of removing the risk of inadvertently leaving the
tube clamped.
Slide 53
Suction A patient who is free from pain, to the degree that an
effective cough can be produced, will generate a much higher
pleural pressure differential than can safely be produced with
suction. This combined with a functional underwater seal will
result in re-inflation of the lung. If a patient cannot re-inflate
his own lung or persistent air leak is preventing re-inflation,
high volume, lowpressure thoracic suction in the range of 3-5kPa
(approx 30-50cmH2O) should be used.
Slide 54
Mobility If appropriate, patients should be encouraged to walk
around. If the drain is on suction the patient will be restricted
to the bedside. Exercise to prevent complications such as a frozen
shoulder or deep venous thrombosis is essential, as are deep
breathing exercises to aid re-expansion of the lung.
Slide 55
Dressings Dressings should be changed daily for the following
reasons:- to enable the insertion site to be monitored for signs of
infection. A swab should be taken from the chest drain site if
there are any clinical signs of infection - to monitor for surgical
emphysema - to ensure the chest drain remains well placed and the
anchor suture is in tact
Slide 56
complications Are rare, 1-3% Chest tube malposition Chest tube
malposition is the most common complication of tube thoracostomy
Lung parenchyma perforation Empyema Subcutaneous tube placement
Perforation of the ventricle or atrium, and abdominal organs
(spleen, liver, stomach, colon) Other complications include
cardiogenic shock from chest tube compression of the right
ventricle, mediastinal perforation with contralateral hemothorax
and pneumothorax bleeding from intercostal artery injury infection
at the chest tube site
Slide 57
1. One of the most common complications is misplacement of the
chest tube. 2. Many life-threatening complications occur when the
tube is first inserted and include insertion of the chest tube into
the lung, stomach, spleen, liver, or heart. 3. A PA and lateral
chest radiograph should always be obtained after a chest tube is
inserted. 4. Pleural infection is another complication of tube
thoracostomy. The administration of antibiotics to patients who
have chest tubes for thoracic trauma may decrease the prevalence of
empyema. 5. The antibiotic chosen should have activity against
Staphylococcus aureus because this is the organism that causes the
most infections.
Slide 58
subcutaneous emphysema, which usually presents as soft tissue
crepitus around the drain site but may rapidly spread to virtually
any place in the body. The presence of subcutaneous emphysema in
patients with tube thoracostomies indicates one of three
possibilities : (a) a side-hole on the chest tube is lying outside
the pleural space within the chest wall, allowing air to enter the
tissue planes (b) the chest tube is blocked. (c) the drainage
system cannot cope with the air leak. The latter situation is
unusual and may be related to a chest tube that is too small or a
massive air leak.
Slide 59
Injection of Materials Through Chest Tubes Fibrinolytic or a
DNAase in a patient with a loculated complicated parapneumonic
effusion. Tetracycline derivative or a different sclerosing agent
through the chest tube in a patient with a malignant pleural
effusion. There is a commercially available adapter called a
Thal-Quick Chest Tube Adapter.
Slide 60
CHEST TUBE REMOVAL Remove when: Original indication for
placement is no longer present Tube becomes nonfunctional. The
following criteria should be met prior to removing the chest tube:
The lung should be fully expanded Daily fluid output should be less
than 100 to 200 mL/day An air leak should not exist, either during
suction or coughing Once these criteria are met, the chest tube can
be placed on water seal. CXR on water seal after 6 hours Some will
clamp the chest tube for four to six hours, then confirm the
absence of pneumothorax prior to removing the chest tube.
Mechanical ventilation does not prevent removal of CT if no air
leak is present. Following inspiration, the patient performs a
Valsalva maneuver and the tube is removed with simultaneous
covering of the insertion site with the gauze dressing
Slide 61
In case Parapneumonic Effusions and Empyema chest tubes should
be left in place until the volume of the pleural drainage is less
than 50 mL for 24 hours and until the draining fluid becomes clear
yellow. The amount of sediment (representing WBCs and debris) in
the collection system should be quantitated daily and the chest
tube should not be removed if more than 5 mL sediments collect
daily.
Slide 62
In case of pneumothorax The chest tube should remain in place
for 24 hours after the lung reexpands and the air leak ceases. If
the chest tubes are removed too soon after the lung reexpands and
the air leak ceases, there is a high likelihood of an early
recurrence if removed within 6 hours of expansion.
Slide 63
Thoracentesis Thoracentesis also known as thoracocentesis or
pleural tap is an invasive procedure to remove air or fluid from
pleural space for diagnostic and therapeutic purposes.
Slide 64
INDICATIONS for Diagnostic thoracentesis Establish the cause of
a pleural effusion. When an effusion is suspected on physical
examination Confirm by radiographic Thoracentesis is not generally
required in patients: Small amount of pleural fluid And a secure
clinical diagnosis (eg, with viral pleurisy) Thoracentesis should
be considered in patients with suspected CHF in the following
circumstances: A unilateral effusion is present, particularly if it
is left-sided Bilateral effusions are present, but are of disparate
sizes There is evidence of pleurisy The patient is febrile The
cardiac silhouette appears normal on chest radiograph The
alveolar-arterial oxygen gradient is widened out of proportion to
the clinical setting
Slide 65
CONTRAINDICATIONS There are no absolute contraindications to
diagnostic thoracentesis Relative contraindications to the
procedure: Anticoagulation or a bleeding diathesis PT or PTT
greater than twice normal Platelet count less than 25,000/mm3 Serum
creatinine concentration greater than 6 mg/dL Active skin infection
at the point of needle insertion A very small volume of pleural
fluid
Reexpansion pulmonary edema Potentially life-threatening
complication of tube thoracostomy It usually occurs unilaterally
after rapid reexpansion of a collapsed lung in patients with a
pneumothorax Can also follow evacuation of large volumes of pleural
fluid (>1.0 to 1.5 liters) or after removal of an obstructing
tumor. The incidence of edema appears to be related to the rapidity
of lung reexpansion. Patients typically present soon after the
inciting event, although presentation can be delayed for up to 24
hours in some cases. A mortality rate as high as 20 percent has
been described. Treatment is supportive, mainly consisting of
supplemental oxygen and, if necessary, mechanical ventilation. The
disease is usually self-limited. Prevention drain only 1-1.5 liters
of fluid at a time; if need to take more, wait 2-4 hours between
drainages
Slide 78
Definition: are Drugs that cause lysis of already formed
thrombus Fibrinolyic drugs 1. Streptokinase. 2. Anistreplase. 3.
Urokinase 4. Tissue plasminogen activators ( t -PA).
Fibrinolytics
Slide 79
Mechanism of Action acts directly or indirectly to convert
plasminogen to plasmin within the thrombus Plasmin degrades fibrin
clots and other plasma proteins (non-fibrin specific)
Slide 80
Slide 81
Use of fibrinolytics in pulmonolgy Fibrinolytic agents are used
to allow complete drainage of locules and partial debridement of
the pleural surface. Instillation of fibrinolytics into the pleural
cavity may help prevent fibrin deposits and loculations. Clinical
success rate ranges from 62 to 100 percent
Slide 82
Streptokinase Is a protein synthesized by B-hemolytic
streptococci. Mechanism of Action acts indirectly by forming
plasminogen-streptokinase complex which converts inactive
plasminogen into active plasmin. It is the least expensive. T 1/2 =
half an hour. 1.5 million units of stk is used.
Slide 83
Side effects 1. Bleeding due to activation of circulating
plasminogen. 2. Hypersensitivity due to antigenicity (rash, fever,
allergic reaction). 3. Hypotension. 4. not used in patients with
streptococcal infections (have antistreptococcal antibodies and may
develop fever, allergic reactions and resistance upon treatment
with streptokinase).
Slide 84
Disadvantages (less than streptokinase alone). 1. Expensive. 2.
Antigenic. 3. Allergic reactions. 4. Bleeding due to minimal fibrin
specificity
Slide 85
Urokinase Human enzyme synthesized by the kidney, obtained from
either urine or cultures of human embryonic kidney cells. acts
directly converting plasminogen to active plasmin. urokinase is
also effective when compared to saline alone for intrapleural
treatment of loculated parapneumonic effusions. Compared with
placebo, intrapleural instillation of urokinase is effective in
improving chest-tube drainage and the radiographic appearance of
the chest; early use of urokinase may be more effective than late
use when catheter drainage alone has failed. Comparison of
urokinasewith streptokinase shows no difference in
effectiveness.
Slide 86
Disadvantages 1. Expensive. 2. Systemic lysis. Advantages 1.
Not antigenic. 2. No Hypotension.
Slide 87
Tissue Plasminogen Activators ( t - PA ) Alteplase - Alteplase
( Single Chain ). - Reteplase ( Deleted Form ). - Tenecteplase All
are recombinant human t - PA. Synthesis by recombinant DNA
technology.
Slide 88
Tissue plasminogen activator (t-PA) has been shown to be
effective in reducing the duration of required chest tube placement
in children with complicated parapneumonic effusions (using 4 mg of
t-PA in 30 to 50 ml of saline instilled through the chest, which is
clamped for 1 hour before applying suction to the tube). No adverse
events have been noted. In our practice, 10 mg of t-PA in 50 ml of
saline is instilled through the chest catheter, followed by 20 ml
of a saline flush. If possible, the patients position is every 10
min for1hbefore the catheter is connected to suction.
Slide 89
complications of intrapleural fibrinolysis hemorrhage, allergic
reactions, transient chest pain promotion of bronchopleural fistula
formation. intrapleural instillation of thrombolytic agents may
alter systemic coagulation parameters, many studies have shown that
this effect does not occur.
Slide 90
Contraindications to thrombolytic therapy Absolute
contraindications include: Recent head trauma or caranial tumor
Previous hemorrhagic shock Stroke Active internal bleeding Major
surgery within two weeks Relative contraindications include: Active
peptic ulcer, diabetic retinopathy, pregnancy, uncontrolled
hypertension