Chest Tube Physiology Review
Summary
TLDRThis 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
- π Eddie Watson from ICU Advantage aims to simplify complex critical care subjects to help ICU staff succeed.
- π The lesson focuses on the foundational physiology behind chest tubes and their clinical applications.
- π‘ 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.
- πͺοΈ Disruptions in pleural space pressure, such as pneumothorax, hemothorax, and pleural effusion, can lead to respiratory compromise and the need for chest tubes.
- π©Ί Chest tubes are used to restore normal physiology by evacuating air, blood, or fluid from the pleural space and re-expanding the lung.
- π« Chest tubes must prevent air from re-entering the pleural space, which would counteract the therapeutic effect.
- π§ The traditional chest tube setup included a three-bottle system with drainage, water seal, and suction components to manage air and fluid evacuation.
- π 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.
- π 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.
- π Active suction can be applied to the chest tube system to enhance the evacuation of air, blood, or fluid from the pleural space.
- π οΈ 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
π 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.
π 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.
π§ 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.
π‘ 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.
Mindmap
Keywords
π‘Chest tube
π‘Pleural space
π‘Pneumothorax
π‘Hemothorax
π‘Pleural effusion
π‘Transpulmonary pressure
π‘Intrapleural pressure
π‘Water seal
π‘Suction
π‘Chest tube collection device
π‘Respiratory compromise
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
information useful if you did please
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