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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