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Respiratory System Care of the critically ill Patient with respiratory
Summary
● Acute Respiratory Distress Syndrome (ARDS)
○ Background ■ Oxygen is diffusion limited – bigger the barrier, the harder it is to move. ■ Normally the alveolar capillary membrane is small so O2 can diffuse with no issues. ○ What it is ■ ARDS is an oxygen related issue. V (air movement)/Q (gas exchange) mismatch. Oxygenation issue. ■ Leaky capillaries fluid crushes alveoli and surrounds alveoli and capillary membrane alveoli capillary membrane has bigger (increased distance) diffusion barrier to oxygen and less surface area in contact to the alveolus to the capillary Less O2 cross barrier Impaired gas exchange hypoxemia. ■ Lungs feel like concrete due to de-recruitment of alveoli and increased resistance in airway. ■ Reduction in surfactant activity and damage to Type 2 pneumocytes ( synthesizing cells of the alveolar surfactant ). ● Surfactant is a phospholipid that decreases surface tension in the lungs preventing the alveoli from sticking together and collapsing at the end of exhalation. ○ Complication ■ Respiratory Failure ● Ventilatory failure causes hypercapnia ● Oxygenation failure causes hypoxemia ● PaO2 < 60mmHg ● SaO2< 90%; or PaCO2 > 50 mmHg (b/c CO 2 accumulates in body; not being diffused) ○ The development of acute hypercapnic respiratory acidosis is an ominous sign and may represent severe ARDS with impending respiratory arrest. ● Risk Factors: ○ Brainstem tumor ○ Acute pancreatitis ○ Cervical and thoracic spine injuries ○ Patient controlled analgesics. ○ Causes ■ Sepsis (most common) ■ Trauma ■ Burns ■ Respiratory inflammation – pneumonia, inhaled toxin, or even aspiration. ■ Transfusion related acute lung injury (TRALI) ■ Near drowning experience ■ Acute pancreatitis - Release of active pancreatic enzymes & cytokines travels to lung and cause inflammation. ○ Assessments ■ Hypoxemia even w/ 100% oxygen given (refractory hypoxia ) ■ Very Sick Patient ■ Decreased pulmonary compliance ■ Altered mental status. ● Agitation, Restlessness, Confusion.
■ Tachypnea and use of accessory muscles ■ Dyspnea and retraction substernally and intercoastally. ■ Bluish nail beds. ■ Non-cardiogenic pulmonary edema ■ Pulmonary fibrosis ● With progression occurs after 10 days of onset of ARDS ● Mechanical ventilation pulmonary lung fibrosis, which may significantly contribute to morbidity and mortality. ● High FiO2 is very toxic pulmonary fibrosis. ■ Abnormal lung sounds are not heard on auscultation because the edema occurs first in the interstitial spaces and not in the airways. ■ Systemic hypotension may occur → result of hypovolemia secondary to leakage of fluid into the interstitial spaced & ↓ cardiac output from high levels of PEEP therapy. ● PEEP can cause impaired venous return. ■ The nursing priority in the prevention of ARDS is early recognition of patients at high risk for the syndrome ● Aspiration prevention ○ Patients who aspirate gastric content are at great risk monitor pt.s on tube feedings, or impaired swallowing. ○ Use suction toothbrush ○ Infection control guidelines ○ High Fowler Position. ○ Diagnostic ■ Rule Out: Brain Natriuretic Peptide (BNP) level – Negative, Left Ventricle Function – Normal or Increased, Pulmonary capillary wedge pressure – Decreased. ■ Infiltrates on x-ray – Ground glass appearance. ● You want to use a chest X-Ray once you have dyspnea and don’t know the cause. ■ ABGs – Gold Standard ● An ABG is the most accurate assessment of hypoxemia. ● Use if pt has respiratory distress and has normal SPO2. ● Will get acid base disturbance, electrolytes and whether there is a low hemoglobin or not for anemia. ● Respiratory Alkalosis is usually seen in patients with this dyspnea. ■ PaO2/FiO2 - < 200 mm Hg. ○ Interventions ■ In general, when O2 is low you want to give oxygen. ● The goal is not to maximize oxygenation but to keep above 95% - SPO2 for healthy adults and between 88-92% for people with COPD. ● Oxygen is used cautiously and should be titrated to the lowest amount needed ■ Intubation and mechanical ventilation ● CO2 management- Decrease TV to decrease pressure in lungs but increase RR to decrease CO2 buildup. ○ Positive Pressure into lung expands unaffected segments but doesn’t expand affected segments. Unequal expansion of lung segments can cause release of inflammatory mediators. ■ Low TV to prevent Barotrauma (damage to lung due to excessive pressure). ● O2 management- Use PEEP. PEEP will improve diffusion barrier by increasing surface area. More important than increasing FiO2. ■ In addition, circulatory support, adequate fluid volume, and nutritional support are important.
○ Frequent flights on airplanes ○ Surgery within 4 weeks. ● Endothelial injury – placing central line, or any other plastic. Smoking. ● Hyper coagulant state – Oral contraceptives, hormone therapy ■ Signs of a DVT or history of a DVT or PE. ■ Pregnancy ■ LE injuries or fractures. ■ Obesity ■ Advancing Age ■ General and genetic conditions that increase blood clotting ■ HF, stroke, cancer (esp. lung/prostate) ○ Signs & Symptoms ■ can be vague; many pts don't have “classic” sx; leads to PE being overlooked often ■ DVT patient presentation ● Unilateral swelling distant to the clot. ● > 2cm greater leg size distant to the greater tuberosity. ■ Main assessments; Respiratory & Cardiac ● Respiratory ○ Wedge infarct can cause: ■ Necrosis – Hemoptysis. ■ Ischemia – Pleuritic chest pain. (Inspiratory) – Appears suddenly. ■ Pulmonary hypertension – right heart strain. ○ V/Q mismatch ■ No perfusion due to pulmonary embolism but there is oxygen available to diffuse. Issue with Q. ■ Hypoxemia ○ Sudden onset of Dyspnea / Tachypnea ○ Productive cough ○ Crackles (fluid accumulation) ○ Tachypnea ● Cardiac ○ Tachycardia (>100) ○ Distended neck veins ○ Syncope ○ Assess LOC (b/c ↓ CO) dizziness and fainting. ○ Systemic hypotension ○ Less than 93% - SPO2. ■ A reading of 90% indicates the client has an arterial oxygen level around 60. ○ Abnormal heart sounds and Abnormal ECG ■ Hypoxemia can trigger anxiety/apprehension and sense of impending doom ● Remaining with patient and providing oxygen can help with this. ● Do not give sedative due to side effect of hypoventilation.
● Morphine sulfate can be prescribed for this. Also prescribed for pain. ■ Diaphoresis (sweating) (pooling of fluid), and Low grade fever. ○ Diagnosis ■ DVT is diagnosed by ultrasound. ■ ABGs ● Hypoxemic, Hypocapnia Respiratory Alkalosis ● Decreased CO2, Decreased O2, Increased pH. ● Chest X-ray should be normal unless you have a chest infarct. ● EKG ○ S1Q3T3 – right heart strain. ■ Low probability ● D-Dimer ○ Elevate for other reasons beyond blood clot. Ex: acutely ill patient or patients with inflammatory problems. ■ Moderate probability ● V/Q scan ○ Can be used with abnormal kidneys but requires normal chest x-ray. ■ High probability ● CT angiogram or CT scan – Best test. – uses IV contrast. – Gold Standard. ○ check renal function first! ○ Check if patient took Metformin in the last 48 hours. ○ Allergies – Iodine. ○ Prevention ■ Post-operative ● Ambulate after surgery ● ROM exercise for extremities ● No pillow under knee ● Assess peripheral circulation Q8h ● Elevate affected limb 20 degrees ● Position changes Q2h as tolerated ● Don’t massages leg muscles; don’t cross legs ● Pneumatic compression stockings. ■ Stop smoking ■ Weight loss ■ Traveling ● Drink water ● get up 5 minutes out of every hour ○ Intervention (Responding) ■ Notify Rapid Response Team first and then give oxygen ■ Adequate gas exchange is priority ■ Oxygen therapy (depends on their RR, and end tidal CO2 monitor) ● Nasal cannula ● 100% non-rebreather ○ Up to 15 L. Turn it up to that. Needs that much flow to get 100% ■ Reposition ■ Bedrest reduces the risk of another clot becoming embolus. ● Reduces metabolic demands and tissue needs for oxygen in lungs. ■ Increasing fluids will help increase fluid volume to help prevent DVT. ■ Maintain venous access
● Non-Invasive Rescue Therapy
○ Includes CPAP, BiPap, HFNC: 20-40 L/min, 100% FiO2. ○ Hypoxic and don’t know why? Use a nonrebreather. Over oxygenate for 15 minutes if necessary. Even if patient has COPD.
● O2 is diffusion dependent – Bigger barrier the less oxygen can move.
○ Surface area and concentration influence oxygenation of a patient. ■ Increasing FiO2 is the same as increasing concentration gradient at alveoli –> increased systemic oxygen. ■ PEEP increases surface area increase systemic oxygen. ○ CPAP – used to manage oxygenation. It is mostly used for CHF. ■ If you have no problems with respiratory acid and you put someone with CHF on BiPap, they might blow off too much CO2 and they will become alkalotic. ■ Normal respiration hovers around 0 pressure. Increasing with inspiration and decreasing with expiration. ■ Positive end expiratory pressure (PEEP) – Continuous pressure to keep alveoli open and to increase alveoli surface area. Prevents alveoli from decruitment or collapsing. ● Breathing cycle doesn’t change when using this. So even with a problem such as leaky capillaries, no problem with collapsing. ● The most serious side effect of PEEP is a tension pneumothorax, the alveoli rupture and air accumulate in the pleura. Impaired Venous return. ● Normal PEEP ventilation should have pressure settings between 5 and 15 cm H2O. ● Client on CPAP with a low O2 sat is to check tightness of the strap and mask. During the night, movement by the client can loosen the straps. By assessing the mask and straps, you can prevent air leaks.
● CO2 is perfusion limited.
○ Modify CO2 by modifying minute ventilation. Minute Ventilation (Mv) = Tidal Volume (Tv) x Respiratory Rate (RR). ■ Tidal Volume – Volume of air that moves into or out of the lungs during quiet breathing. ● Should be 6 to 8 ml/kg ○ Decrease CO2 by increasing Tv or RR. ■ If having acidosis patient will breathe hard and fast to decrease CO2. ○ BiPAP – It is used to manage CO2. ■ It is used to manage COPD and blow-off excess CO2. ■ Has a built in PEEP and then also Pressure support over PEEP (PSOP). When patient breathes in, extra pressure, PSOP or the (Bi) PAP, allows extra air to enter lungs. ● Good for patient in an acute respiratory distress. ● Goes well with lung compliance.
○ Forces air in quickly breathing in and when breathing out, air exits lungs immediately
with elastic recoil. This effectively increases the tidal volume. ● Decrease CO2 by increasing TV by increasing PSOP. ■ Indications: ● Hypercapnia, Respiratory failure, Worsening COPD, Respiratory acidosis. ○ PSOP – CO2 and PEEP – O2. ○ Sleep Apnea ■ CPAP machine delivers just enough air pressure to a mask to keep your upper airway passages open, preventing snoring and sleep apnea. ■ BiPaP machine can be used as well for complicated sleep apnea.
● Mechanical Ventilator Support
○ Indicators to be ventilated ■ To protect airway – Provide oxygen to keep it open ■ General Anesthesia ■ Respiratory distress ■ Help improve gas exchange in lungs ○ Ventilator Settings ■ Assist Control (AC) – Continuous Mandatory Ventilation (CMV) ● Full support mode; ventilator takes over work of breathing ● Tidal volume & ventilatory rate (respiratory rate) are preset (“mandatory breaths”) ● Can be used w/ pressure-regulated mode or volume-regulated mode of delivery ● If pt begins to breathe, ventilatory delivers preset tidal volume whether the breath is mandatory or patient induced ○ But rate is set by patient...they can increase their own rate ● Disadvantage: vent continues to delivery preset tidal volume even when spontaneous breathing rate increase ○ Can cause hyperventilation and respiratory alkalosis ○ Investigate & correct causes of hyperventilation (ie. pain, anxiety, acid- base imbalances) ● Volume control (VC) – Every breath delivered (mandatory or spontaneous) is the same set tidal volume. ○ Good mode for lung protection. ○ Monitor pressure for barotrauma. ● Pressure control (PC) – Every breath delivered (mandatory or spontaneous) is a set pressure for a set time ○ Requires you to monitor volumes to avoid volutrauma or hypoventilation. ■ Weaning off of ventilator ● Pressure Support ○ Every time the patient initiates a breath the machine provides support in the form of extra pressure. ■ This will give a specific tidal volume. ■ Has apnea settings incase patient becomes apneic. ● Synchronized intermittent mandatory ventilation (SIMV) ○ Similar to AC ■ tidal volume and ventilatory rate are preset (Mandatory breaths if pt. doesn’t breathe on own) ■ Can be used w/ pressure-regulated mode or volume-regulated mode ○ Difference→ ■ Allows for spontaneous breathing at patients own rate and tidal volume between ventilator breaths ■ With this method, the respiratory rate is gradually decreased until the client assumes all of the work of breathing on his or her own. The respiratory rate frequently is decreased in increments on an hourly basis until the client is weaned and is ready for extubation. ■ This action coordinates breath between ventilator and patient. ■ Breath’s patient does on their own without preset tidal volume can be supported with pressure support. ● T-Piece (Briggs device)
● Increased PIP ● Decreased lung compliance ■ Low ● Cuff leak
○ Pilot balloon on artificial airway is flat
○ When patient can talk (air escapes from the mouth)
● Check the connections or disconnections of the ventilator. ● Displacement of the endotracheal tube or tracheostomy tube ● Pt stops breathing (apnea) in SIMV/CPAP mode or pressure support ventilation ● Generation of extreme negative pressure by patient ● An exaggerated inspiratory pressure. ○ Ventilator Associated Pneumonia. ○ What is it? ■ The ET or tracheostomy tube bypasses the body’s filtering process; it provides direct access to the lower respiratory system for bacteria. ■ Infection w/in 48 hours of trach ■ Aspiration of colonized fluid from the mouth or stomach can be a source of infection. ■ Infection prevention through strict adherence to infection control, especially handwashing during suctioning & care of the tracheostomy or ET tube, is essential, as is meticulous oral care. ■ Symptoms include fever, positive sputum culture, and elevated WBC ○ Best practices to reduce it/ Nursing interventions ■ Elevate head of bed to at leas t 30 degrees ■ Oral care ● Suctioning every 2 hours and prn to prevent mucus build-up ● Chlorhexidine rinse helps prevent bacterial overgrowth and infection. ● Provide meticulous mouth care every 12 hours. ● Preoxygenate for 30 seconds and suction for no more than 10 seconds. ■ Ulcer prophylaxis ● gastric secretions can burn hole in GI tract→ Stress ulcers ● Complication that can occur to pts. on long term vents ● PPIs and H2 blockers prophylactically ■ Prevent aspiration ■ Repositioning every 2 hours to prevent skin breakdown. ■ Pulmonary hygiene, including chest physiotherapy, postural drainage, & turning & positioning ■ DVT prophylaxis ■ Monitor for signs and symptoms of infection ■ Daily sedation assessment (sedation holidays) & spontaneous breathing trials. ● Sedation holidays can help avoid drug accumulation and oversedation. They may allow your patient time to reorient, and even reduce psychological trauma from critical care stresses.
● Rapid Sequence Intubation (RSI) and Endotracheal Tube (ET) Intubation
○ Idea is to get it in quick and reduce risk of aspiration ○ Nurses can intubate ○ Steps ■ Prepare equipment ■ C-spine immobilization ● Maintain a patent airway through positioning (head-tilt, chin-lift) and the insertion of an oral or nasopharyngeal airway until the patient is intubated. ■ Preoxygenate (3-5 minutes) ● FiO2 – 100% ● Want them have about 12-16 breaths/min ● Given before sedation, anesthetics and paralytics. ● End tidal CO2: Level of CO2 that is released at end of exhaled breath. Pt should not be able to breathe in any CO2. ○ Can help verify tube placement. ○ Can help determine if pt has a good seal around mouth. ● End tidal O2: Want this to be 80% or higher. Good way to tell that lungs is full of oxygen before giving anesthetics. ■ Intubation ● Ensure that each intubation attempt lasts no longer than 30 seconds, preferably less than 15 seconds. After 30 seconds, provide oxygen by means of a mask and manual resuscitation bag to prevent hypoxia and cardiac arrest. Suction as necessary. ● Cricoid pressure is done once paralytics are given. Used to clamp esophagus. Done for 30 seconds. ● Larynxscope is used to visualize vocal cords for endotracheal tube to be placed. ● Inflate cuff to protect airway. ○ Endotracheal tube have a pilot tube to inflate cuff to prevent anything going down into the airway. ○ Adult tube sizes range from 7 to 9 mm. ● Both Sedatives and Paralytics decrease oxygen demand. ● Sedative is given first to help with anxiety/irritability or agitation. ○ Amnesia ■ Gaba A stimulants ■ Propofol is most often used especially in controlled environment such as OR regardless of swings in BP.
○ If only on one side, it may be too far in, so pull back a bit
● Also listen to epigastric area
○ If you hear gurgling, means tube is going into stomach
■ If that is the case, take it out! And get a new tube ● Inspect chest rise and fall ● Skin color should change (so color should start to come back) ● Put end tidal CO2 monitor and see color changes (will change colors in presence of carbon dioxide) ● Don’t use adult end tidal cap on PEDS patient ● Document how far down you went (there are markers on the tube) ● Last, confirm w/ chest x-ray ■ Assessment ● Cuff leak test – determine if there is any edema around pilot ballon.
○ Prevents post extubation complications.
● Prevent movement of tube by patient ● Check pilot balloon ● Soft wrist restraints ● Mechanical sedation ● Assess for pressure injury from device ● If patient is gagging, they may need more sedation ● The first step when a patient becomes agitated or restless, after checking the ventilator settings, is to increase the flow rate and then reassess. ● Assess the need for suctioning every 2 hours and suction only as needed (being sure to preoxygenate the patient before suctioning).
○ No more than 10 seconds of suctioning. An endotracheal tube that is inserted too far
can cause absent breath sounds, but the lack of breath sounds most likely would be on the left side because of the degree of curvature of the right and left mainstem bronchi. ■ Extubation ● The patient is asked to cough immediately after removal of the ET tube to help clear secretions. ● Should sit in semi-Fowler position rather than lying down for resting. ● If during the weaning process the patient shows signs of respiratory distress, place patient on previous ventilatory settings. ● Signs of obstruction includes mild dyspnea, coughing, hoarse, and inability to expectorate secretions. Can progress to stridor.
○ Position patient in semi-fowler position and monitor.
● Chest Trauma
○ Rib Fracture ■ Usually from blunt trauma to the chest. ■ Risk for deep chest injury (penetrating trauma): pulmonary contusion, pneumothorax & hemothorax ■ Can injure liver, spleen, kidney, lungs, great vessels and nerves of upper limb ■ Diagnose ● Chest X-ray ■ Symptoms ● Pain on movement ● TTP ● Possible bruising. ● Inspiratory pain.
● Shallow respirations. ● Defensive splinting of chest ○ Ineffective clearance ○ Decreased breathing depth. ■ Complications ● In the elderly, who may not breathe enough (because it hurts to do so), atelectasis and pneumonia may develop (and kill them). – Do not Splint. ● SOB – Can lead to respiratory acidosis. – Hypoventilation. ■ Interventions ● Support respiratory drive ○ Breathing (inspiration)= pain, so pain management is important & main focus to maintain adequate ventilation ■ Opioids ● downside: can cause respiratory depression ● Morphine, Hydromorphone, Hydrocodone ● NSAIDS ● Epidural anesthesia ● PCA ● Intercostal nerve block for severe pain ■ Pain control is also important postoperatively so patient can maintain good pulmonary hygiene.
- Can splint with a pillow against ribs for breathing and coughing exercises.
- Fractured ribs reunite spontaneously in 6 weeks. ● Oxygen ■ Definition inspiration, “puffing out” of same flail piece of thorax during expiration ● Trauma was so severe that visceral organs are probably affected. ● Gas exchange, coughing, & clearance of secretions impaired ● ■ How it occurs ● Result of fractures of > 3 adjacent ribs in > 2 places ● Usually, one side of the chest ● Results from: ○ 1. Huge blunt chest trauma (often high-speed car crashes) ○ 2. Bilateral separations of ribs from their cartilage connections to each other anteriorly w/o rib fracture can be due to CPR. ■ Diagnose ● Paradoxical chest movement —“Sucking inward” of the flail piece of thorax during ○ Flail Chest
● Tachypnea ● Dullness to percussion ● Bloody sputum ■ Interventions : ● Maintain ventilation & oxygenation ○ Fluids as prescribed ■ Avoid crystalloids (NS and LR) and use colloids (blood and albumin) ○ Positioning: High Fowler ○ O2 management - Use PEEP. PEEP will improve diffusion barrier by increasing surface area. More important than increasing FiO2. ○ Diuresis ○ Side lying (good lung down) ○ Incentive spirometer ○ Pleurisy ■ Is an inflammation of the visceral and parietal pleurae. ■ The inflammation prevents the parietal and visceral pleural surfaces from gliding over each other with respiration. ■ As a result, the client experiences pain, especially with inspiration. ○ Pneumothorax/Open/Closed/Tension ■ Definition
● A product of penetrating or blunt trauma rib fracture, air rushes into the pleural space
and compresses the lung. ○ causes loss of negative pressure it the chest cavity, rise in chest pressure, and reduction in vital capacity can lead to lung collapse. ■ Open pneumothorax describes when an injury creates a hole in the chest wall that allows air from the environment to enter the pleural cavity. ■ Closed pneumothorax refers to air that enters the pleural cavity from the lungs themselves. ● A closed pneumothorax occurs due to a defect of or damage to the pulmonary parenchyma, the portions of the lungs involved in gas exchange. Lung disease -- such as chronic obstructive pulmonary disease (COPD), cystic fibrosis, lung cancer, or pneumonia -- can be the source of the damage. ■ Spontaneous pneumothorax which is a leak from the lung allows air to enter the negative pressure pleural space until there is no longer a pressure difference or until the leak closes. ■ Tension pneumothorax ● Causes: ○ Traumatic tension pneumothorax ■ Open chest wound, like a stab wound or a gunshot ■ Closed trauma, like a rib fracture ○ Mechanical ventilation ■ High positive pressure during the inspiratory phase can force air from the lungs into the pleural space, causing a rapidly growing pneumothorax. ■ Rarely, a spontaneous tension pneumothorax can occur in the absence of any precipitating factors. ○ Torn mainstem bronchus ● Assessment
○ One way valve effect – Air enters forcefully. ■ Air continues to enter pleural space during inspiration; air does not exit during expiration ○ Medical emergency. quickly fatal if not detected & treated ○ Impaired cardiac filling ■ Compression of the mediastinum compresses the heart and prevent the heart from filling normally. ○ Impaired venous return ■ Positive intrathoracic pressure disrupts pressure gradient compresses the inferior vena cava decreased filling of heart, and ↓ CO ● Symptoms ○ Hypoxia or severe respiratory distress cyanosis ■ Dyspnea – mechanical compression of both lungs. ■ Tachypnea ○ Unilateral absent breath sounds. – Big Difference from simple pneumothorax. ■ No muffled lung sounds. ○ Chest asymmetry on involved side of chest ○ Tracheal deviation toward unaffected side ○ Jugular vein distention ○ Unilateral hyperresonance. ○ Obstructive Shock – hemodynamic instability ■ Tachycardic, and hypotensive ○ Diagnose clinically and not with a chest x-ray. ● Intervention ○ Needle Decompression or needle thoracostomy to temporize ■ Converts a tension PTX into a simple PTX ○ Place chest tube for definitive management. ■ 4th intercostal space, other end attached to a water seal drainage system until lung reinflates. ○ Supplemental O ○ Simple Pneumothorax ■ Causes: ● Patients with COPD may have spontaneous pneumothorax. ■ Assessment ● Diagnosis ○ X-ray shows vertical lung shadows inside the chest since air floats. ■ This will cause a lung collapse. ● Physical Exam ○ Hyperresonance ○ Decreased breath sounds ○ Decreased fremitus or whispered pectoriloquy
● Go to operating room for open thoracotomy (opening up chest) if at least 1000 ml blood loss or 3cc/kg/hr = 150-200 ml/hr for 3 to 4 hours ○ An expiratory volume of less than 15 ml/kg is considered to be a sign of poor prognosis. The chances of survival are very bleak.
● Chest Tube
○ A chest tube drain placed in the pleural space allows lung re-expansion and prevents air and fluid from returning to the chest.
○ The drainage system consists of one or more chest tubes or drains. ○ Chest tube should be kept below the level of the patient to prevent backward flow. ○ A functioning chest tube system includes having an occlusive dressing (airtight) over the chest tube insertion site. ■ The insertion site must be covered to prevent infection and form an airtight seal around the opening. ○ Patient change position to increase drainage. ○ Looping the tubing prevents direct pressure on the tube itself and keeps tubing off the floor. ■ Addresses safety and potential clogging. ○ Wet ■ Water in the water seal and suction control can evaporate over time so watch the water and add as needed. ■ When no suction is applied, the air exits the pleural space via the chest tube across a water seal only when there is sufficient positive pressure generated, as with coughing or straining. With suction, air removal is accelerated. ■ Three chambers ● 1.Drainage collection connected to tube from patient (tube penetrates chamber shallowly, as does tube connecting chamber one to two). ● 2. Water seal chamber→ prevents air or fluid from moving back up to tubing system and into chest. ● 3. Suction control chamber. ○ Dry ■ This chest drainage system has no water column to control suction but u ses a suction monitor bellow (looks like an orange accordion) that balances the wall suction and you can adjust wall suction pressure using the rotary suction dial on the side of the system. ■ It allows for higher suction pressure levels, has no bubbling sounds, and water does not evaporate from it as with other systems. ○ Drainage collection chamber ■ This collection chamber is an expansion of your pleural space. ■ The fluid is measured hourly during the first 24 hours. ■ This drainage fluid must never fill to the point that it comes into contact with any tubes! If the tubing from the patient enters the fluid, drainage stops and can lead to a tension pneumothorax.” ■ Dark red blood = Normal. Document. ■ Bright red blood over 100 ml/hr (after 1 st^ hour of placement) = Notify HCP. ○ Water seal chamber ■ 2 cm of water is the minimum needed in the water seal to prevent air from flowing backward into the patient. Check the water level every shift and add sterile water to this chamber to the level marked on the indicator. ■ The water in the water-seal chamber column normally rises 2 to 4 inches during inhalation and falls during exhalation, a process called tidaling. ■ Air bubbling through the water seal chamber intermittently is normal (intrathoracic pressure is greater than atmospheric pressure) when the patient coughs or exhales ● This shows that lungs has not re-expanded yet. ● OPPOSITE is true if patient on Positive Pressure Mechanical ventilation ● The bubbling of the water in the water-seal chamber indicates air drainage from the patient. ■ When the air in the pleural space has been removed, bubbling stops. ● A blocked or kinked chest tube also can cause bubbling to stop. ■ Excessive bubbling in the water-seal chamber may indicate an air leak. – NOTIFY HCP. ● Provider should check whether chest tube is inside wall still. Patient could be moving which could create holes right outside the chest wall. This can cause air to leak into chest tube. ● Check connections as well for the tube. Loose connections will have air enter water seal. ● Can also be due to if wall suction is high. ○ Suction Control Chamber (Wet Suction) ■ Suction setting is usually set to -20cmH2O and atmospheric vent of the suction system is usually submerged in 20 cm of water.
