Chest Tube Physiology Review

Summary

This ICU Advantage video lesson, hosted by Eddie Watson, delves into the physiology behind chest tubes, essential for healthcare professionals in the ICU. The video explains the normal functioning of the pleural space and how disruptions such as pneumothorax, hemothorax, and pleural effusion necessitate chest tube placement. It covers the pathophysiology of these conditions, the goals of chest tube insertion, and the mechanics of chest tube systems, including the transition from traditional three-bottle setups to modern, streamlined devices, emphasizing safety and efficiency in patient care.

Takeaways

• 😀 Eddie Watson from ICU Advantage aims to simplify complex critical care subjects to help ICU staff succeed.
• 📚 The lesson focuses on the foundational physiology behind chest tubes and their clinical applications.
• 💡 Normal pleural space physiology involves a balance of pressures with the lungs' elastic recoil and the chest wall's outward force creating a negative intrapleural pressure.
• 🌪️ Disruptions in pleural space pressure, such as pneumothorax, hemothorax, and pleural effusion, can lead to respiratory compromise and the need for chest tubes.
• 🩺 Chest tubes are used to restore normal physiology by evacuating air, blood, or fluid from the pleural space and re-expanding the lung.
• 🚫 Chest tubes must prevent air from re-entering the pleural space, which would counteract the therapeutic effect.
• 💧 The traditional chest tube setup included a three-bottle system with drainage, water seal, and suction components to manage air and fluid evacuation.
• 🔄 Modern chest tube collection devices have simplified the process, combining the functions of the three-bottle system into a single, safer, and more efficient unit.
• 📉 The water seal in the chest tube system acts as a one-way valve, allowing air and fluid to exit but preventing air from re-entering the pleural space.
• 🌀 Active suction can be applied to the chest tube system to enhance the evacuation of air, blood, or fluid from the pleural space.
• 🛠️ The level of suction applied to the chest tube can be controlled and adjusted to ensure patient safety and effective treatment.

Q & A

What is the main purpose of a chest tube?

The main purpose of a chest tube is to evacuate air, blood, or fluid from the pleural space, restore the normal negative intrapleural pressure, and allow the lung to re-expand, ultimately helping to heal the injury that caused the condition.

What are the three main disruptions in the normal process of breathing that can lead to the need for a chest tube?

The three main disruptions are pneumothorax (air in the pleural space), hemothorax (blood in the pleural space), and pleural effusion (fluid accumulation in the pleural space).

What is the normal function of the pleural space in relation to lung function?

The pleural space, located between the visceral and parietal pleura, maintains a relatively negative intrapleural pressure compared to atmospheric pressure, which helps keep the lungs expanded against the chest wall and facilitates lung function.

What is transpulmonary pressure and how does it relate to lung expansion?

Transpulmonary pressure is the difference between intrapulmonary pressure and intrapleural pressure. It is a pressure gradient that, when positive (intrapulmonary pressure higher than intrapleural pressure), causes the lungs to expand against the chest wall.

How does a pneumothorax disrupt normal lung function?

A pneumothorax introduces air into the pleural space, which can equalize the pressures and eliminate the transpulmonary pressure gradient. This results in the lung collapsing, leading to impaired gas exchange and symptoms like dyspnea and hypoxia.

What is the role of the water seal in a chest tube setup?

The water seal acts as a one-way valve in the chest tube setup, preventing air from re-entering the pleural space while allowing air, blood, and fluid to be evacuated from the pleural space.

Why is a two-bottle system used in chest tube management?

A two-bottle system is used to separate the drainage from the water seal, allowing for continuous drainage collection without altering the hydrostatic pressure in the water seal, which is crucial for maintaining the one-way valve function.

What is the purpose of adding suction to a chest tube setup?

Adding suction to a chest tube setup helps to actively pull air, blood, and fluid out of the pleural space faster, improving drainage efficiency in cases where there is a large volume of accumulation.

How does a modern chest tube collection device simplify the traditional three-bottle system?

A modern chest tube collection device combines the functions of the drainage bottle, water seal, and suction control into a single unit, making it easier to set up, reducing the risk of disconnection or leaks, and maintaining the safety and efficiency of the chest tube system.

What is the typical amount of suction applied in a chest tube setup and why is it commonly used?

The typical amount of suction applied is negative 20 centimeters of water. This level of suction is commonly used because it provides effective drainage without causing excessive or potentially traumatic suction on the patient's lung tissue.

Outlines

00:00

😐 Introduction to Chest Tube Physiology

This paragraph introduces the topic of chest tube physiology, explaining the basics of how we breathe and the disruptions that can occur, necessitating the use of a chest tube. Eddie Watson, from ICU Advantage, aims to simplify complex critical care subjects for viewers. The paragraph also discusses the importance of understanding the physiological changes that warrant chest tubes, and provides an overview of the pleural space and the pressures involved in normal breathing, including the concept of trans-pulmonary pressure.

05:02

😕 Disruptions in Pleural Pressure and Indications for Chest Tubes

This section delves into the disruptions of intrapleural pressure, such as pneumothorax, hemothorax, and pleural effusion, which can lead to respiratory compromise. It explains how the presence of air, blood, or fluid in the pleural space can disrupt the normal negative intrapleural pressure, affecting lung expansion and leading to conditions like dyspnea and hypoxia. The paragraph also outlines the indications for chest tube placement, particularly in trauma situations where these conditions can be life-threatening.

10:02

🔧 Functionality and Principles of Chest Tube Insertion

The paragraph discusses the principles and goals of chest tube insertion, which include evacuating the pleural space of air, blood, or fluid, restoring the normal negative intrapleural pressure to re-expand the lung, and healing the underlying injury. It provides a basic overview of what a chest tube is and how it works, creating a path for drainage while preventing air from re-entering the pleural space. The explanation includes the historical use of a one-bottle system with a water seal to act as a one-way valve, facilitating the outflow of air while preventing backflow.

15:03

💡 Evolution of Chest Tube Systems and Modern Devices

This part of the script describes the evolution from the traditional three-bottle system to modern chest tube collection devices. It explains the function of the two-bottle system, which addresses the issue of drainage affecting the hydrostatic pressure of the water seal, and the addition of a third bottle for controlled suction to enhance drainage. The paragraph highlights the complexity of the old system and the advantages of modern devices that combine all necessary functions into a single, safer, and more efficient system, making it easier to set up and reducing the risk of malfunction.

Keywords

💡Chest tube

A chest tube is a medical device inserted into the pleural space to drain air, blood, or fluid, which can disrupt normal lung function. In the video, chest tubes are discussed as a critical intervention for conditions like pneumothorax, hemothorax, and pleural effusion, aiming to restore normal respiratory physiology by evacuating the pleural space and re-expanding the lung.

💡Pleural space

The pleural space is the potential area between the two layers of pleura surrounding the lungs, namely the visceral and parietal pleura. It is central to the video's theme as disruptions in this space, such as accumulation of air, blood, or fluid, necessitate the use of chest tubes to maintain respiratory function.

💡Pneumothorax

Pneumothorax refers to the presence of air in the pleural space, which can result from a chest wall injury or a defect in lung tissue. In the script, pneumothorax is discussed as a condition that can lead to respiratory compromise, potentially requiring chest tube insertion to re-establish normal intrapleural pressure.

💡Hemothorax

Hemothorax is characterized by the accumulation of blood in the pleural space due to injury to the chest wall or lung tissue. The video explains that hemothorax, like pneumothorax, disrupts the negative intrapleural pressure and can be a clinical indication for chest tube placement.

💡Pleural effusion

Pleural effusion is the abnormal buildup of fluid in the pleural space. The script describes it as a disruption that can be due to various causes, and it may also require chest tube drainage to alleviate respiratory symptoms and restore lung function.

💡Transpulmonary pressure

Transpulmonary pressure is the difference between intrapulmonary (alveolar) pressure and intrapleural pressure. The video script uses this concept to explain the pressure gradient that allows the lungs to expand and the importance of maintaining this gradient for proper lung function, which chest tubes help restore.

💡Intrapleural pressure

Intrapleural pressure is the pressure within the pleural space. The video emphasizes the importance of this pressure remaining negative relative to atmospheric pressure for normal lung expansion. Disruptions leading to a positive intrapleural pressure, such as pneumothorax or hemothorax, are discussed as indications for chest tube placement.

💡Water seal

A water seal is a one-way valve mechanism used in chest tube systems to prevent air from re-entering the pleural space while allowing air, blood, or fluid to escape. The script describes how this principle is applied in traditional chest tube setups and modern devices to maintain patient safety.

💡Suction

Suction is the application of negative pressure to facilitate the drainage of air, blood, or fluid from the pleural space through a chest tube. The video explains how suction can be applied actively to enhance the evacuation process, with the level of suction being controlled to prevent damage to lung tissue.

💡Chest tube collection device

A chest tube collection device is a modern medical apparatus that integrates the functions of drainage, water seal, and suction control into a single system. The script contrasts these devices with older, more complex multi-bottle setups, highlighting the advantages of simplicity, safety, and efficiency in managing pleural space disruptions.

💡Respiratory compromise

Respiratory compromise refers to a situation where an individual's ability to breathe effectively is diminished. In the context of the video, conditions like pneumothorax, hemothorax, and pleural effusion can lead to respiratory compromise, underscoring the importance of chest tube placement in restoring normal respiratory function.

Highlights

Introduction to the basics of mechanics of breathing and disruptions leading to the need for a chest tube.

Explanation of the pleural space and its normal physiology, including the roles of the visceral and parietal pleura.

Discussion on trans-pulmonary pressure and its significance in lung expansion.

Overview of disruptions in intrapleural pressure such as pneumothorax, hemothorax, and pleural effusion.

Impact of disruptions on transpulmonary pressure and lung function leading to respiratory compromise.

Indications for chest tube placement in cases of respiratory compromise due to pneumothorax, hemothorax, or pleural effusion.

Chest tube's role in restoring normal physiology by evacuating air, blood, or fluid from the pleural space.

Description of a chest tube's basic function and its insertion into the pleural space.

Risk of air re-entry into the pleural space and the importance of preventing it with a one-way valve.

Historical use of a one-bottle system with a water seal to create a one-way valve for chest tubes.

Introduction of a two-bottle system to address limitations of the one-bottle system and improve drainage.

Use of active external suction to enhance drainage from the pleural space.

Risks associated with excessive suction and the introduction of a third suction bottle to regulate it.

Transition from the traditional three-bottle system to modern chest tube collection devices.

Explanation of the inner workings of a modern chest tube collection device and its advantages.

Details on how modern devices combine the benefits of the three-bottle system into a single, safer, and more efficient setup.

Upcoming lesson details on managing chest tubes and what to look for in patient care.

Conclusion and call to action for viewers to subscribe and engage with the channel for future lessons.

Transcripts

in the last lesson we talked about the

basics of mechanics of how it is that we

breathe sometimes though we have

disruptions in this normal process which

ultimately can lead to the need for a

chest tube in this lesson i'm going to

cover some of the foundational

information behind the chest tube

physiology and why it is that we use

them

[Music]

all right you guys welcome back to

another video lesson from icu advantage

my name is eddie watson and my goal is

to give you guys the confidence to

succeed in the icu by making these

complex critical care subjects easy to

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link down in the description so to have

a good understanding of chest tubes we

need to first make sure that we

understand the changes in physiology

that would warrant them and why that is

we need to then cover how it is that

chest tubes work and help to restore

these disruptions in physiology and so

let's actually quickly review over the

normal physiology of the pleural space

and so again here we have our patient

their thorax and their lungs now in that

previous lesson which i'm going to link

to up above i did cover this all in

depth here but here surrounding the

lungs we have the visceral pleura and

then the parietal pleura and in between

we have the potential space the pleural

space the lungs have that elastic recoil

pulling them inward and then the chest

ball works to keep the chest open

together these create the relatively

negative intrapleural space compared to

our intrapulmonary or atmospheric

pressure now one thing that i do want to

cover real quickly that i didn't talk in

that previous lesson about is actually

something we call trans-pulmonary

pressure and really just the difference

between our intrapulmonary pressure and

the intrapleural pressure is going to be

our trans-pulmonary pressure so this is

actually a pressure gradient so again we

know pressure normally flows from high

to low and then normally we have the

relatively high alveolar or that

intrapulmonary pressure and then the

relatively low intrapleural pressure and

this causes the lungs to expand out

against the chest wall this relatively

negative intraplural pressure overcomes

the collapsing force of lung recoil now

if the intrapleural pressure remains

negative the lungs are going to stay

expanded all right so now let's actually

talk about different disruptions of this

intrapleural pressure and the first one

that i want to talk about real quick is

going to be our pneumothorax so here we

have pneumo which means air thorax is

the chest and this is essentially air

that's in the chest or in that pleural

space and this air can either come from

the outside so think if we have some

sort of hole in the chest wall or it can

come from the inside so here if we think

we have some kind of defect in our lung

tissue that this can allow air to get

into that pleural space this air leak

can either be a spontaneous or an

acquired but i will go over that in more

detail in a future lesson then the next

disruption is actually going to be our

hemothorax so here we have heme which

means blood and then again thorax is

chest and so this is essentially where

we have blood in this pleural space so

once again this blood can either come

from injury to the chest wall or to the

lung tissue itself and then the last

disruption i want to talk about is

actually going to be our pleural

effusion and this is essentially an

accumulation of fluid into the pleural

space and typically when we're talking

about a pleural effusion we're actually

using this to describe the buildup of

normal pleural fluid in the pleural

space but this can actually be fluid

from different areas as well all right

so now that we've covered those

different disruptions let's talk a

little bit about the pathophysiology and

having air blood or fluid in that

pleural space is actually going to

disrupt the normal negative intrapleural

pressure that we have in that space so

if we have air that comes in like let's

say it's from the atmosphere the higher

pressure air is going to be introduced

into this relatively negative interpolar

space until those pressures balance out

the same also goes if we have blood or

fluid that accumulates in this

intrapolar space this is again going to

be resulting in a relatively positive

intrapleural pressure and so having a

positive intrapolar pressure that is

becoming more positive is actually going

to impact the transpulmonary pressure so

again think that intrapulmonary pressure

minus our intrapleural pressure again

when the intrapolar pressure is negative

transpulmonary pressure actually is

positive which results in that the lung

is going to stay expanded out against

the chest wall as the intrapleural

pressure becomes less negative or more

positive then that trans-pulmonary

pressure gradient is actually eliminated

giving us a transpulmonary pressure of

zero in this case here the elastic

recoil the lung is now unopposed and

this leads to collapsing of the lung and

as you'd expect a collapsed lung doesn't

exchange gas very well and this then

results in that dyspnea and hypoxia that

we often see thus if our patient has a

pneumo or hemothorax or a pleural fusion

that's actually causing some sort of

clinical respiratory compromise for the

patient then this is actually going to

be an indication for a chest tube

placement and especially true in trauma

situations where a pneumothorax can

result in tension pneumothorax or

hemothorax can be the result of a large

volume of bleeding both of these can be

potentially life-threatening now if they

do have a small pneumohema or pleural

fusion and they don't have any

respiratory symptoms that are

accompanying that then they can

potentially just be observed without

actually doing a chest tube placement

and so by inserting this chest tube

really our goal is to try to restore

this normal physiology and there's a

couple principles that we're really

trying to look to achieve with this and

the first one is going to be that we

want to evacuate that pleural space of

either the air blood or fluid then we

also want to restore that normal

relative negative pressure of the

intrapleural space to re-expand the lung

and then ultimately we want to heal the

injury that took place so whether this

was lung tissue or the chest wall that

really led to this condition and the

beautiful thing about a chest tube is it

actually accomplishes all of these so

let's actually get in and talk about

what exactly is a chest tube and this is

just going to be a quick overview of

this right now i'm going to go a little

bit more in depth in the next lesson but

at its most basic a chest tube is a tube

that's inserted from the outside through

the chest wall and into the pleural

space and this is going to allow air

blood and or fluid to be drained out of

the pleural space so the chest tube here

is creating a path of communication from

that pleural space to the outside we

want the air blood or fluid to flow out

in order to re-establish that normal

relatively negative intra plural

pressure and then allow that lung to

re-expand now once we have the chest

tube in place one of our concerns with

having that tube from the outside to the

pleural space is the risk of air flowing

back into that pleural space if we have

air moving back in that pleural space

then we're effectively creating a

pneumothorax and this is really going to

be counterproductive to what we're

trying to achieve so we really need to

ensure that air and fluid can drain out

while also not allowing air back in so

that kind of rolls us right into how it

is that a chest tube works so to allow

this air blood and fluid to flow out of

the pleural space we must have the chest

tube connected to some sort of

environment where the pressure is

relatively negative compared to that of

the intrapleural pressure and then as

mentioned we also need to prevent air

from coming back into the pleural space

via that chest tube so we need to have

some sort of one-way valve and to kind

of help you understand that concept we

can kind of look at what we used to do

in the past and that's using a system of

bottles so let's start out with this one

bottle system and so here what we have

is our bottle and then we have the chest

tube coming from our patient down into

this bottle and then being submerged in

some water that we have here and so i'm

going to explain why this is in just a

minute here but we want to have the end

of this chest tube submerged two

centimeters under this water and this

water here is essentially going to act

as a one-way valve something that we

refer to as water seal now along with

that chest tube coming in we are going

to have an output from the bottle that

just goes from the air of the bottle to

the outside atmosphere and so really the

concept that you can think of with this

setup here is to think of a drink with a

straw now as you know you can blow air

through the straw and it's going to

bubble out via the drink but if you try

to suck on that straw you can't draw any

air in via that straw the fluid in this

case the water here is going to serve as

that one-way valve the water seals off

the air from entering into the chest

tube creating that one-way valve but

still allows air to leave the system but

not re-entering it at the same time so

then ultimately with this if the

intrapleural pressure is higher than the

hydrostatic pressure of the chest tube

submerged in the water then air is going

to bubble out and exit via the output

vent and this is the point of having

that submerged two centimeters because

it creates the right amount of

hydrostatic pressure so this is going to

allow for the reduction of the

intrapleural pressure helping to restore

that relatively negative intrapolar

pressure and thus allowing the lung to

re-expand and so this simple setup is

actually really good for if our patient

has a pneumothorax so we're trying to

evacuate air but it's not going to work

so well if there's any sort of drainage

so here if we have drainage coming out

that this is actually going to increase

the level of the water and thus

increasing that hydrostatic pressure

that's required to be overcome for that

chest tube system to drain if that

hydrostatic pressure builds up and it

becomes greater than what our

intrapleural pressure is then the

evacuation is going to stop and as you

can imagine if air blood and fluid

remains in the intrapleural space that

negative pressure is not going to be

restored and the lungs are not going to

fully expand so this is a really

important concept that we need to try to

figure out a way of how we work around

this and so here let's actually

introduce our two bottle system and so

to fix this problem we're gonna add a

second collection bottle before the

water seal bottle and so here for this

setup we're actually gonna have our

chest tube come down to this first

drainage bottle and it's actually just

gonna drain into the air here then the

output from this first bottle is going

to go to our water seal bottle and go

down and be a submerged two centimeters

under the water and then again having

that output to the atmosphere and so the

whole point of this is if we're trying

to evacuate air the air is just going to

move right through the system just like

it did when we had it directly hooked up

to the water seal itself but if we have

drainage then the drainage is actually

going to come down it's going to collect

in our first drainage bottle and does

not make any changes to the level of the

water in the water seal bottle allowing

for the proper hydrostatic pressure so

that we can continue to move our fluid

and our air out of our intrapleural

space the beauty of this is that we can

collect our drainage we can see it we

can observe it but we're going to

preserve the proper functioning of that

one-way valve with the water seal now

the important thing to know though is

that with this water seal collection

that this is actually a passive process

so it's going to be driven by the

positive intrapleural pressure

associated from that pneumohemothorax or

that pleural effusion in some cases

though our patients may have large

amounts of air blood or fluid and we may

need some sort of better drainage and so

we can actually use an active external

suction to help pull that air blood and

fluid out of the pleural space faster

and so essentially instead of having our

output on our water seal bottle going to

the atmosphere if we had suction here

that that would add extra driving

pressure to help to pull the air and the

fluid out of that pleural space but the

problem is that we can't just hook up

the suction to this outflow vent of the

water seal the reason for this is

there's the risk of excessive and really

potentially traumatic suction and this

can lead to a hematoma or damage to the

lung tissue around the holes that we see

in the end of our chest tube so to allow

for this external suction to be applied

safely we actually add a third suction

bottle to our setup here and the point

of this third suction bottle is to

prevent too much suction from being

applied and so to do this we're actually

going to add a third bottle at the very

end here and then we're going to add our

suction to this bottle and then we're

going to have the output from the water

seal bottle go to this new third bottle

so both the suction and the output from

our water seal are gonna go to the air

on this third bottle but then for this

third bottle we're gonna have more water

in here and we're actually gonna have a

third tube that goes and is submerged

from the atmosphere down into this water

and the depth that we have this third

tube submerged is actually going to be

our level of suction and this is going

to be based on how far this third tube

is submerged so we can have this 10

centimeters 20 centimeters 30

centimeters 40 centimeters the further

down we have it the more suction that

this is going to allow to go to

ultimately our patient and through their

chest tube and this kind of might not

make sense on

why this random third tube would have

have any effect on the suction that's

being applied to our patient but the

reason for this is when we hook up the

suction and we crank the suction up on

our system let's say we have that middle

tube submerged to 20 centimeters any

pressure that is above that is actually

going to then pull air from the

atmosphere it's going to bubble out

through this water and go to the suction

instead of continuing to increase the

pressure further down the system and

ultimately to our patient's chest tube

and our patient themselves and this

level of suction is what you probably

have heard of when we talk about having

a certain amount of suction set up to

our patient and typically negative 20

centimeters of water is the most common

amount of suction that we apply and so

again the beauty of this is that no

matter what the wall suction has turned

up to the max amount of suction to the

chest tube is going to be based on the

submerged length of that third tube so

as you can see this is a pretty complex

setup of bottles and tubes in order to

achieve the effect that we want from our

chest tube insertion evacuating air

evacuating fluid while maintaining

relative safety for our patient and

believe it or not this is actually how

it used to be done back in the day they

would have these different bottles and

these different tubes and have things

set up just like this now fortunately

for us we no longer use this three

bottle system so because there's so many

bottles and tubes each of those actually

poses a potential for something to

either become disconnected or to allow a

leak and this would ultimately disrupt

the function of the chest tube and or

potentially introduce air back into the

pleural space again not good now modern

chest tube collection devices combine

all the benefits of our three bottle

system into a single system it's much

easier to set this up to use it and

reduces the potential areas for the

system to malfunction and so here's an

example of a modern chest tube

collection device and this is going to

be the inner workings of it here and

let's do a quick overview of this system

and really how it kind of relates to the

different parts of our three bottle

system so coming up in over here we have

the chest tube that's going to be

connected to our system and so first

it's actually going to enter the

drainage system which is going to be the

equivalent of the drainage bottle and

this is going to allow that drainage to

be collected and measured and then from

here we're going to have the air that

moves down into our water seal so again

you can see our water seal is at two

centimeters that we talked about then

from there the air is gonna go up into

the suction area and the suction area

can either be wet suction so using

actual water and having the amount set

again just like that third tube in our

third bottle adjusting how far it's

submerged and changing the amount of

pressure that we're applying or more

commonly we actually have the dry

suction setup which still creates this

one-way pop-off valve but we can

actually dial in and set the pressure to

what we want it to be so you can kind of

see we have all the different parts of

our three bottle system but nicely

contained in this one device that we use

and we can still adjust the suction and

ensure that we have a functioning system

to efficiently and safely drain our

patients either pneumothorax hemothorax

or pleural effusion and in the next

lesson i am going to go into more detail

about this system and sort of how we

manage and things that we're looking for

with this but i wanted to give you guys

a good overview of how it is that all

this works

why it is that it works and ultimately

what we're looking to achieve with our

patient and sort of those underlying

disruptions and physiology that really

kind of influence why we have the chest

tube so i hope that you guys found this

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