Presence of air in the pleural space
Primary spontaneous pneumothorax Secondary spontaneous pneumothorax Tension pneumothorax Traumatic pneumothorax
Most common In tall thin people Rupture of tiny bleb at the apex of the
lug Clinical signs: acute chest pain
shortness of breath (at rest
or on exertion) May be recurrent
Size determines management Observation and repeat X-ray Needle aspiration ICD After two pneumothoraces on the same side – surgery Pleurectomy Pleurodesis
As a result of lung disease e.g. TB, COPD or lung abscess
Penetrating trauma
Usually accompanied by haemothorax – haemopneumothorax
Haemothorax – accumulation of blood in the pleural space
Bleeding from chest wall, heart, major vessels or lungs
Lung contusion – injury to lung parenchyma, oedema and blood collecting in the alveoli and an inflammatory reaction to blood components in the lung.
Lung contusion affects gas exchange - ARDS
Site of air leak acts as one-way valve – air enters pleural space during inspiration but cannot escape during expiration
Volume of air and pressure in hemithorax – compression of lung
Mediastinal shift away from compressed lung
Possible shift of trachea and kinking of great vessels
Clinical signs - deviation of tracheaabsent breath soundsacute respiratory
distress↑ jugular venous
pressurehypotension
Life-threatening – insert ICD
System used to drain air and fluid from thoracic cavity and regain / maintain re-expansion of lung by creating normal negative pressure
Effective gas exchange only possible if lung can expand to allow ventilation
Visceral and parietal pleura Between them 10ml of serous pleural
fluid, produced by pleural membranes Fluid lubricates surfaces, reduces
friction Negative pressure between pleura,
counteracts tendency of lungs to recoil If air or fluid enter pleural space –
negatve pressure lost – lung will collapse partially or fully
Diameter of tube depends on size of patient and what is being drained
Smaller drain – air, larger drain – fluids Location of substance, determines
placement of tube Pneumothorax - tube anteriorly 2nd or 3rd
intercostal space or mid axillary line 3rd and 5th space Fluids - mid axillary line 6th space
Prevents air re-entering pleural space End of tube is submerged 2cm under
water level Hydrostatic resistance of +2cmH2O When pressure in intrapleural space is
higher than +2cmH2O, air moves from higher (intrapleural) to lower pressure (drainage chamber)
Drainage chamber has a vent to allow air to escape and not build up in chamber
Fluids will drain by gravity Keep bottle below level of patient’s
chest If you need to lift the bottle (with
transfers), clamp it Minimize clamping time One-bottle system Two-bottle system – one for air and one
for fluid Three-bottle system – suction applied to
third bottle
Disposable (all-in-one) three-bottle system
Waterless suction system
Swing
Intrapleural pressure changes during inspiration and expiration transmitted to tube
Inspiration (more negative), fluid moves up the tube
Expiration – opposite direction Movement during normal breathing –
swing Suction reduces swing
No swing
Tube kinked or patient lying on it Lung re-expanded Dependant fluid-filled loop of tubing
Bubbling
Bubbling in bottle – air leak from pleural space
Bubbling in suction chamber – suction is applied
Bubbling with cough – small air leak Bubbling on expiration – moderate air
leak Bubbling during inspiration and
expiration – large air leak
No bubbling
Absence of air leak
When examining UWSD – ask patient to take deep breath and observe swinging and bubbling.
If no bubbling with above – ask patient to cough.
< 100ml in 24 hours – remove tube > 100ml per hour or sudden increase –
tell medical staff Large amounts of blood over short time
– haemorrhage Large amounts of haemoserous
drainage – hypovolaemia, hypotension, low haemoglobin
Gentle bubbling in suction chamber Vigorous bubbling - ↑ evaporation No bubbling – insufficient suctioning
Keep bottle upright – tip of tube under water
Bottle below patient’s chest, clamped if held above chest
Beware of occlusion of tubing If tube disconnected from bottle – clamp
and reconnect as soon as possible If chest drain comes out – cover wound
with gloved hand and call for help Positive pressure (CPAP, IPPB) can
increase air leak, constant monitoring
Patients should move around with their drains
Encourage shoulder movements on side of drain and good posture
Patients may be disconnected from suction, but check with staff first
If patient may not be disconnected – walking on spot
Disconnect tubing from suction, don’t switch suction off
Localised breathing exercises
Cardiovascular exercises
Posture correction
Shoulder - maintain ROM
Positioning – check with doctor. May sometimes position on operated side or just sitting for 3-6 days
Complication – pulmonary oedema. Whole CO through one lung. Report positive fluid balance with tachycardia, tachypnoea and hypoxaemia
After lobectomy and pleurectomy - no absolute contra-indication to positioning in side-lying and trendellenburg
Pryor, J.A. and Prasad, S.A. 2009. Physiotherapy for respiratory and cardiac problems. Adult and paediatrics. Edinburgh: Churchill Livingstone
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