Traumatic pneumothorax (stab or gunshot wound).Some conditions that may require a chest tube drainage system include (Bauman & Handley, 2011 Perry et al., 2018): These tubes are placed directly under the sternum and are referred to as mediastinal chest tubes (Perry et al., 2018). A chest tube may also be inserted to drain the pericardial sac after open heart surgery. If there is fluid in the pleural space, the chest tube is inserted at the fourth to fifth intercostal space, at the mid-axillary line. If air is in the pleural space, the chest tube will be inserted above the second intercostal space at the mid-clavical line. The location of the chest tube depends on what is being drained from the pleural cavity. Figure 10.8 Chest tube samples note the various holesįigure 10.9 Chest wall structure note the lung’s pleura Another type of chest tube called a Heimlich valve is discussed later in this chapter. A large amount of fluid or air cannot be absorbed by the body and will require a drainage system in order to optimize oxygenation (Bauman & Handley, 2011 Perry et al., 2018). Small amounts of fluid or air accumulating in the pleural space are often absorbed by the body without a chest tube.įigure 10.10 demonstrates a pneumothorax. Negative pressure is disrupted when air, or fluid and air, enters the pleural space and separates the visceral pleura from the parietal pleura, preventing the lung from fully expanding and collapsing. A patient may require a chest drainage system any time the negative pressure in the pleural cavity is disrupted and causes respiratory distress.
The pleural space is the space between the parietal and visceral pleura, and is also known as the pleural cavity (see Figures 10.9). volume and mode of ventilation.A chest tube, also known as a thoracic catheter, is a sterile tube with a number of drainage holes inserted into the pleural space (see Figure 10.8). If exhaled tidal volumes are less than 75% of inhaled tidal volumes, evaluate and consider changes in tidal volume, frequency, PEEP, inspiratory time, pressure vs.Maintain pH between 7.25 and 7.45 by adjusting the rate.consider FiO 2 adjustments to maintain saturations between 88% – 95%.After careful consideration of initial settings Hess and Kacmarek (2019) suggest the following for ventilator management in patients with air leaks. Permissive hypercapnia and permissive hypoxemia (PaO 2 > 50 mm Hg) should be considered. Higher FiO 2 may be used lieu of higher pressures. Plateau pressures should be minimized, kept below 28 cm H 2 O and driving pressure less than 15 cm H 2 O. Tidal volumes should be set from 4-8 mL/kg PBW with an inspiratory time between 0.5-0.8 sec. Additionally, frequent adjustments of cycling criteria may be needed, as well as, trigger sensitivity since suction pressure of the chest tube may trigger the ventilator. Use of pressure support should be used cautiously, as inspiration only terminates when flow is decreased to a certain level and the ventilator may not cycle appropriately if the leak is greater than this level. An air leak may also increase with spontaneous breathing. Some patients may need paralysis to reduce air leak and maintain acceptable cardiopulmonary function. Leak compensation should be turned off with PAL. volume should carefully be considered in determining which mode best minimizes the leak. While pressure control ventilation (PCV) controls peak pressures, caution must be used as it may increase the leak, as it maintains the higher pressure throughout the inspiratory phase of the cycle. cited a case study that demonstrated volume loss through a fistula increased from 15% to 54% with the addition of 15 cm H 2 O PEEP. This will work to minimize peak airway pressure (Paw). To reduce the leak, both inspiratory pressure and PEEP need to be minimized. The challenge and goal for mechanical ventilation management becomes aimed at techniques to minimize the pressure gradient across the fistula, reduce the leak and allow healing to occur. When secondary to barotrauma or direct lung injury, mortality has been reported from 50-60%. PALs can be identified by either an intermittent (during inspiration) or continuous air leak through a chest tube.Īir leaks in mechanically ventilated patients are associated with an increase in morbidity and mortality. It can occur from trauma, surgery, vascular line placement, tumors, or from specific diseases, including, but not limited to, COPD and ARDS. Most commonly, it can be seen as a pneumothorax, subcutaneous emphysema, pneumomediastinum, or pneumopericardium. Extra-alveolar air can come in many different forms.
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