Question

1. What are chest Drainage systems, and how do you care for a patient with Post-operative chest tubes, and complications

2. What are Upper respiratory Infections, and how does the nurses assess the patient

Answer 1

1.A chest tube is a flexible plastic tube that is inserted through the chest wall and into the pleural space or mediastinum. It is used to remove air in the case of pneumothorax or fluid such as in the case of pleural effusion, blood, chyle, or pus when empyema occurs from the intrathoracic space. It is also known as a Bülau drain or an intercostal catheter. Insertion of chest tubes is widely performed by radiologists, pulmonary physicians and thoracic surgeons. Large catheters or small catheters are used based on each situation that the medical doctor encounters. In the current review we will focus on the chest drain systems that are in use.

Pressure around the lungs is lower than atmospheric pressure outside the body.

The aims for an adequate chest drainage system to be fulfilled are: (I) remove fluid & air as promptly as possible; (II) prevent drained air & fluid from returning to the pleural space, restore negative pressure in the pleural space to re-expand the lung. Thus, a drainage device must: (I) allow air and fluid to leave the chest; (II) contain a one-way valve to prevent air & fluid returning to the chest; (III) have design so that the device is below the level of the chest tube for gravity drainage. An underwater seal chest drainage system is used to restore proper air pressure to the lungs, re-inflate a collapsed lung as well as remove blood and other fluids. The system is a two-chambered or three-chambered plastic unit with vertical columns bringing measurements marked in milliliters. The thoracic drainage devices cover a wide range and have evolved considerably since their introduction. The basic design principle of these systems has been the avoidance of air entrance in the pleural cavity during the various phases of the respiratory cycle and continuous drainage of air and fluid from the pleural cavity. A key issue in the successful treatment of patients is the understanding of how these systems function. The application and development was based on the original one-bottle system. The understanding of this principal system introduces us to the mechanism of function
It consists of a bottle which collects and contains the fluid and at the same time seals air leak (leakage barrier-water seal). A rigid straw is immersed into the bottle, so that its tip is located 2 cm below the surface of the saline solution, which is put into the bottle. The other end of this rigid straw is connected to the thoracic drainage tube placed in the pleural cavity. In order to decompress the pressure from the air leak, there is an opening of one-way decompression valve (vent) through which the system is depressurized. It is important to remove this valve cover before connecting the system to the patient.

When the pleural pressure is positive, the pressure in the rigid straw becomes positive, and if the positive pressure in the rigid straw is greater than the depth to which the tube is immersed in the saline solution, then air will enter in the bottle and then depressurized by vent into the atmosphere. If the pleural pressure is negative, it will move liquid from the bottle to the rigid straw and air will not enter the pleural cavity or the rigid straw. This system is called water seal because the water bottle seals the pleural cavity from the air or liquid from the outside of the body. Just like a straw in a drink, air can push through the straw, but air can’t be drawn back up the straw.

It is clear that when the rigid straw is above the liquid level in the bottle, the system will not operate consistently developing pneumothorax.

However, when a significant quantity of liquid is drained from the pleural cavity of the patient, the liquid level will rise, thus requiring a greater pressure on the rigid straw to remove effectively additional air from the pleural cavity to the bottle. Practically, this system works if only air is leaving the chest, because if fluid is draining, it will add to the fluid in the water seal, and increase the depth, and 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. As a result, the one-bottle system works efficiently for uncomplicated pneumothorax.

Another disadvantage of this system is that the positioning of the bottle at a level higher than the patient’s chest causes liquid passing into the pleural cavity
Two-compartment system (Figure 1B)
For the aforementioned reasons of inefficient function of the one-bottle system in cases of pleural fluid effusion, it has been introduced the two-compartment system. This system is preferred over one-bottle system when large quantities of liquid are drained from the pleural cavity. With this system, the first bottle (closer to the patient) collects the drainage and the second bottle is the water seal, which remains at 2 cm (water seal and air vent). Therefore, the degree of water seal does not increase as fluid accumulates in the drain bottle. The water-seal bottle is the key for chest drainage, as it includes a place for drainage to collect and a one-way valve that prevents air or fluid from returning to the chest. Both the one and two-bottle chest drainage systems rely on gravity to create a pressure gradient by which air and fluid leave the chest. Keeping the drainage system below the level of the patient's chest enhances gravity drainage; additional pressure is created when the patient exhales or coughs. However, if the patient has a large air leak into the pleural space, gravity drainage may not be sufficient to evacuate the chest, and suction may be required. This also means the addition of a third bottle to the system—a suction control bottle.

CARE:
Keep the system closed and below chest level. Make sure all connections are taped and the chest tube is secured to the chest wall;
Ensure that the suction control chamber is filled with sterile water to the 20 cm-level or as prescribed. If using suction, make sure the suction unit’s pressure level causes slow but steady bubbling in the suction control chamber;
Make sure the water-seal chamber is filled with sterile water to the level specified by the manufacturer. You should see fluctuation (tidaling) of the fluid level in the water-seal chamber; if you don’t, the system may not be patent or working properly, or the patient’s lung may have reexpanded;
Look for constant or intermittent bubbling in the water-seal chamber, which indicates leaks in the drainage system. Identify and correct external leaks. Notify the health care provider immediately if you can’t identify an external leak or correct it;
Assess the amount, color, and consistency of drainage in the drainage tubing and in the collection chamber. Mark the drainage level on the outside of the collection chamber (with date, time, and initials) every 8 hours or more frequently if indicated. Report drainage that’s excessive, cloudy, or unexpectedly bloody;
Encourage the patient to perform deep breathing, coughing, and incentive spirometry. Assist with repositioning or ambulation as ordered. Provide adequate analgesia;
Assess vital signs, breath sounds, SpO2, and insertion site for subcutaneous emphysema as ordered;
When the chest tube is removed, immediately apply sterile occlusive petroleum gauze dressing over the site to prevent air from entering the pleural space;
Don’t let the drainage tubing kink, loop, or interfere with the patient’s movement;
Don’t clamp a chest tube, except momentarily when replacing the chest drainage unit, assessing for an air leak, or assessing the patient’s tolerance of chest tube removal, and during chest tube removal;
Don’t aggressively manipulate the chest tube; don’t strip or milk it;
A patient who is free from pain, to the degree that an effective cough can be produced, will generate a much higher pressure than can safely be produced with suction;
If a patient cannot re-inflate his own lung, high volume, low pressure "thoracic" suction in the range of 15-25 cm of water can help;
Patients on mechanical ventilators cannot produce an effective cough and therefore suction is advised;
Close surveillance is required by nursing staff trained to recognize faults in the drainage and suction system. It is better to remove suction than to use a faulty device;
The depth of the water in the suction bottle determines the amount of negative pressure that can be transmitted to the chest, NOT the reading on the vacuum regulator;
There is no research to support this number of −20 cm H2O, just convention. Higher negative pressure can increase the flow rate out of the chest, but it can also damage tissue;
The water seal chamber and suction control chamber provide intrathoracic pressure monitoring. Remember that in gravity drainage without suction the level of water in the water seal chamber = intrathoracic pressure;
Slow, gradual rise in water level over time means more negative pressure in pleural space and signals healing. Goal is to return to −8 cm H2O;
When we apply suction: Level of water in suction control + level of water in water seal chamber = intrathoracic pressure.0

COMPLICATIONS:
A common complication after thoracic surgery that arises within 30–50% of patients are air leaks. Here, digital chest drainage systems can provide a remedy as they monitor intra-pleural pressure and air leak flow, constantly.

Major insertion complications include hemorrhage, infection, and reexpansion pulmonary edema. Injury to the liver, spleen or diaphragm is possible if the tube is placed inferior to the pleural cavity. Injuries to the thoracic aorta and heart can also occur.

Minor complications include a subcutaneous hematoma or seroma, anxiety, shortness of breath (dyspnea), and cough (after removing large volume of fluid). In most cases, the chest tube related pain goes away after the chest tube is removed, however, chronic pain related to chest tube induced scarring of the intercostal space is not uncommon.

Subcutaneous emphysema indicates backpressure created by undrained air, often caused by a clogged drain or insufficient negative pressure.

2.UPPEER RESPIRATORY INFECTIONS:

• Common cold
• Sinusitis: Inflammation of the sinuses
• Epiglottitis: Inflammation of the epiglottis, the upper part of the trachea that helps protect the airways from foreign particles. Swelling here is dangerous because it can block air flow
• Laryngitis: Inflammation of the larynx (voice box)
• Bronchitis: Inflammation of the bronchial tubes

Causes and Risk Factors

URIs can be caused by both viruses and bacteria. There are several sub-types within each of these categories. For viruses, these include:

• Rhinovirus
• Adenovirus
• Coxsackie virus
• Parainfluenza virus
• Respiratory syncytial virus
• Hyman metapneumovirus

For bacteria, these include:

• Group A beta-hemolytic streptococci (GABHS)
• Corynebacterium diphtheriae (diphtheria)
• Neisseria gonorrhoeae (gonorrhea)
• Chlamydia pneumoniae (chlamydia)
• Group C beta-hemolytic streptococci

Several actions, events or conditions can increase the risk of a URI, including:

• When someone sick sneezes or coughs without covering their nose and mouth. This causes droplets containing viruses to be sprayed into the air.
• Closed areas or crowded conditions, such as hospitals, institutions, schools and daycare centers.
• When you touch your nose or your eyes—infection occurs when secretion touches the nose or eyes.
• During fall and winter (September to March) while people are more likely to be inside.
• When humidity is low—indoor heating promotes the survival of many viruses that lead to URIs.
• If you have a weakened immune system.

Symptoms

Symptoms of a URI may include:

• Runny nose, nasal congestion, sneezing, cough and sputum production (these are considered the most common symptoms)
• Fever
• Fatigue
• Headache
• Pain during swallowing
• Wheezing

Diagnosis and Treatment

In most cases, people with URIs know what they have and are visiting the doctor to find symptom relief. Most diagnoses can be made using medical history and a physical exam. If needed, tests like throat swabs, X-rays or CT scans might be used for a diagnosis.

URI treatments include:

• Cough suppressants
• Expectorants
• Vitamin C or zinc
• Nasal decongestants
• Steam inhalation and gargling with salt water
• Analgesics like acetaminophen and NSAIDs can help with fever, aches and pains

Prevention

There are a few things you can do to help protect against URIs:

• Wash your hands regularly with soap and water to reduce exposure to secretions.
• Avoid being in close contact with sick people.
• Sanitize commonly-touched objects like remote controls, phones and doorknobs when anyone in the house may have a URI.
• Cover your mouth and nose if you are sick.
• Stay home if you are sick.