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What is a Chest Drain? Chest drains, also referred to as chest tubes, under water sealed drainage (UWSD), thoracic catheter, tube thoracostomy, or intercostal drain. Chest drains provide a method of removing air & fluid substances from the pleural space. The idea is to create a one-way mechanism that will let air/fluid out of the pleural space and prevent outside air/fluid from entering into the pleural space. This is accomplished by the use of an underwater seal. The distal end of the drainage tube is submerged in 2cm of H2O. They use flexible plastic tubes which are inserted through the chest wall and into the pleural space between the 5th and 6th intercostal space in the mid-axillary line, venting the space which allows air back out. [1] Basics of Breathing Breathing is stimulated by the build up of CO2 levels in the bloodstream. When the diaphragm descends there is an increase in interthoracic space and a decrease in interthoracic pressure. Intrapulmonary pressure also decreases which draws air into the lungs as the pressure outside of the lungs is greater than the pressure inside. Weak diaphragm decreases the available volume making it harder to draw air in and also increases the risk of developing pneumonia. Lungs are surrounded by pleura which have a layer of fluid between them. The visceral pleura is attached to the lungs while the parietal pleura is attached to the ribs. The lungs are elastic and want to recoil with the pleura, this elasticity creates the negative pressure which causes the lungs to inflate. Intrapleural pressure is always negative however during inspiration it is more negative (-8cm H2O) whilst during expiration when the diaphragm relaxes it’s less negative (-4cm H2O). If this intrapleural pressure is lost e.g. during a stabbing, the loss of negative pressure will cause the lung to collapse and a chest drain will be needed to restore the correct pressures. [2] Principles of underwater seal drainage The underwater seal prevents air re-entering the pleural space. Usually, the distal end of the drain tube is submerged 2cm under the surface level of the water in the drainage (or collection) chamber. This creates a hydrostatic resistance of +2cmH20 in the drainage chamber. Normal intrapleural pressure is negative. However, if air or fluid enters the pleural space, intrapleural pressure becomes positive. Air is eliminated from the pleural space into the drainage chamber when intrapleural pressure is greater than +2cmH20. Thus, air moves from a higher to lower pressure along a pressure gradient. The drainage chamber has a vent to allow air to escape the chamber, and not build up within the chamber. Fluids will drain by gravity into the drainage chamber, and will not spill back into the pleural space if the bottle is always kept below the level of the patient's chest. If the bottle needs to be lifted above the chest, the tubing should be briefly double clamped as close to the patient as possible. The movement and unclamping should take place as quickly as possible to minimise clamping time. [2] Components & Types of Chest Drain Systems Components
Systems
Mechanism of action[edit | edit source]
Potential Indications for Chest Drain insertion[edit | edit source]Chest drains are inserted as an invasive procedure to; Remove fluid/air from the pleural space/mediastinum, and/or Re-expand the lungs and restore negative intrapleural pressure and respiratory function.[1] Conditions that require a chest drain include;
Complications of Chest Drains[edit | edit source]
Insertion of a Chest Drain[edit | edit source]Local anaesthetic and intravenous analgesia are mandatory, as the placement is a painful procedure. The use of sedation should always be discussed with a senior emergency doctor, as it can potentially worsen the patient's clinical condition.[6] Establish patient on continuous cardiac monitoring and pulse oximetry Procedure as per 'The BTS Guidelines for the insertion of a chest drain, 2003'[6]
[7] Assessment of a Chest Drain[edit | edit source]As part of a physiotherapy objective assessment a specific examination of a chest drain should be performed. Important aspects that should be noted include the following;
Always ensure you know the location of chest drain clamps in case you need them in an emergency!! Handling of Chest Drain[edit | edit source]
Clamping[edit | edit source]It is never appropriate to clamp chest drains for mobilisation / transport of patients. NEVER clamp in tension pneumothorax or if still bubbling. When would you clamp a drain?
Accidental Disconnection of Tube[edit | edit source]
Criteria for removal of chest drains[edit | edit source]
Physiotherapy Treatment Options[edit | edit source]Techniques to remove air from pleural space:
-Before and after treatment it is important to check the drain for any changes – if changes occur you need to document them and report them to the relevant member of the MDT eg) excessive drainage or no pressure swing during inspiration and expiration in the water seal level. -Look at patients vitals, response to treatment, positioning, etc
Key Points for treating patients with Chest Drains[edit | edit source]
References[edit | edit source]
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