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a personal guide to M A N A G I N G Chest Drainage
a personal guide to
M A N A G I N G
Chest Drainage
Table of ContentsYour personal guide to Managing Chest Drainage is a quickand easy reference to help extend your understanding ofchest tube drainage and to help answer questions which maycome up from time to time. It is provided as an educationalservice of Atrium, the leading producer of chest drainagesystems. This booklet has been prepared as an educationalaid only and is not intended to replace any medical ornursing practices or hospital policies. Due to numerousmodel types available, it is important to carefully read andfollow each corresponding product insert prior to use.
IntroductionMaking It Simple To Understand . . . . . . . . . . . . . . . . . . . . . 4
How Water Seal CDUs FunctionThe Basic Operating System . . . . . . . . . . . . . . . . . . . . . . . . . 5Fluid Collection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6Water Seal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6Suction Control . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
The Atrium SystemTimeless Design . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8Features, Benefits, Function . . . . . . . . . . . . . . . . . . . . . . . . 10Product Feature Summary . . . . . . . . . . . . . . . . . . . . . . . . . 12
System Set UpOpen Package . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14Requirements For Set Up . . . . . . . . . . . . . . . . . . . . . . . . . . .14Four Step Set Up . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
What To Check During System OperationSuction Control Stopcock . . . . . . . . . . . . . . . . . . . . . . . . . . 18Verifying System Operation . . . . . . . . . . . . . . . . . . . . . . . . 18Placement Of Unit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18Observing Water Seal For Patient Air Leaks . . . . . . . . . . . . 19
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Graduated Air Leak Monitor . . . . . . . . . . . . . . . . . . . . . . . . .19Sampling Patient Drainage . . . . . . . . . . . . . . . . . . . . . . . . . .19Observing Changes In Patient Pressure . . . . . . . . . . . . . . . 20Atrium’s High Negativity Float Valve . . . . . . . . . . . . . . . . . . 20Manual High Negativity Vent . . . . . . . . . . . . . . . . . . . . . . . . 21Positive Pressure Protection . . . . . . . . . . . . . . . . . . . . . . . . 21Adding Water To Water Seal . . . . . . . . . . . . . . . . . . . . . . . . 21Adding Water To Suction Control . . . . . . . . . . . . . . . . . . . . 21To Prescribe Suction PressureGreater Than -20cmH2O . . . . . . . . . . . . . . . . . . . . . . . . . 21
To Lower Suction Control Pressure . . . . . . . . . . . . . . . . . . 22Recording Drainage Volume . . . . . . . . . . . . . . . . . . . . . . . . 22In-Line Patient Tube Connector . . . . . . . . . . . . . . . . . . . . . 22Patient Tube Clamp . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22Swing Out Floor Stand . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23Multi-Position Hangers . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23Gravity Drainage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23System Disconnection . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
Anatomy And Physiology ReviewAnatomy Of The Chest . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24Why The Lungs Are Expanded . . . . . . . . . . . . . . . . . . . . . . 25The Mechanics Of Breathing . . . . . . . . . . . . . . . . . . . . . . . . 26
Why Water Seal CDUs Are UsedClinical Needs For Chest Tube Drainage . . . . . . . . . . . . . . . 27
Problems To Check For During CDU Use . . . . 30
Chest Tube PlacementChest Tube Insertion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31Chest Tube Nursing Responsibilities . . . . . . . . . . . . . . . . . 32
Troubleshooting GuideQuestions And Answers . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
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Introduction
■ Making It Simple To UnderstandTo restore the chest to its normal condition, all air and fluidmust be removed, and the source of an air leak must beclosed. The purpose of any chest drainage device is to helpre-establish normal vacuum pressures by removing air andfluid in a closed, one-way fashion.
The need for chest drainage is also required following openheart surgery and chest trauma to evacuate any poolingblood which, if left in the mediastinal cavity, can causecardiac distress or tamponade. Hence, chest drainage isindeed a life-saving procedure and one of the most importantservices a physician and nurse clinician can render.
While the practical application of water seal chest drainagetechniques are relatively simple, sometimes the chest drainand its accompanying terminology may appear complex.However, water seal chest drainage systems are actuallyquite simple to manage and easy to understand. It is ourhope that review of this educational aid booklet will helpenhance your working knowledge of chest drainage andfurther familiarize you with Atrium’s traditional water sealoperating system.
■ Customer ServiceIf a question or need arises for customer service, productinformation, or to request inservice educational material, weinvite you to call or FAX Atrium’s hotline anytime.
In the U.S.A. 1-800-528-7486Outside the U.S.A. 603-880-1433FAX 603-880-6718www.atriummed.com
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To suction
Air leakmonitor
Collectionchamber
From patient
Water sealchamber
How Water Seal CDU’sFunction
■ The Basic Operating SystemToday’s water seal drainage systems are comprised of a one-piece, 3-chamber setup, which provides separate functions offluid collection, water seal (which serves as a simple one-wayvalve), and suction control. An easy way to describe the one-way action of a water seal is to refer to a cup of water and astraw. If one were to blow air into a submerged straw, airwould bubble out through the water. Now if you wanted todraw the air back through the straw, you would only drawwater. Hence, when chest drainage came into light manyyears ago, the one-way action of a water seal (water bottleand straw concept) provided a simple but ideal means forevacuating air and not allowing it to return to the patient.
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Suctioncontrolchamber
To this day, nothing is more consistent, accurate, or asdependable as water and gravity. Consequently, today’swater seal operating systems not only provide a simplemethod to maintain a required amount of vacuum in apatient’s chest, but now provide more patient diagnostics,improved air leak detection, high negative pressureprotection, and options for autotransfusion.
■ Fluid CollectionIn a traditional water sealoperating system, fluids drainfrom the patient directly into alarge collection chamber via a 6-foot patient tube (3/8" I.D). Asdrainage fluids collect in thischamber, the nurse will recordthe amount of fluid that collectson a specified schedule. Hence,an easy-to-read, well calibratedcollection chamber is one of themost important features for anynew chest drainage system.
■ Water SealThe water seal chamber, which is connected inseries to the collection chamber, allows air topass down through a straw or narrow channeland bubble out through the bottom of the waterseal. Since air must not return to the patient, awater seal is considered one of the safest andcost effective means for protecting the patient,in addition to being a very useful diagnostic tool.The water seal column is calibrated and acts asa water manometer for measuring intrathoracicpressure. As changes in intrathoracic pressureoccur, fluctuation in the water level can be
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observed in this calibrated column. Such fluctuationsprovide the clinician an indication of how the patient isprogressing. With the addition of an advanced float valve atthe top of the water seal, a patient can also be protected fromthe dangers of accumulating high vacuum pressures or highnegativity, which can be induced from chest tube stripping ormilking. Today’s more sophisticated systems provide suchpatient protection both manually and automatically.
■ Suction ControlThe use of suction helps overcome an airleak by improving the rate of air and fluidflow out of the patient. The simplest andmost cost effective means of controllingsuction is by a calibrated water chamber.This is accomplished with a suction controlchamber, which is an atmospherically ventedsection containing water and is connected inseries with the water seal chamber andcollection chamber. By adding or removingwater in the suction control chamber, thechest drain effectively controls the amount ofsuction imposed on the patient. The lowerthe water content, the lower the imposedsuction. The higher the water level, thehigher the imposed suction.
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The Atrium System
■ Timeless DesignFrom the beginning, Atrium has pioneered advances in waterseal design with compact chest drains that are smaller, userfriendly, and cost effective. We’ve continued ourcommitment to product innovation with the latest series ofOcean™ water seal chest drains featuring a familiar water sealoperating system with convenient ATS compatibility, essentialfor today’s hospital-wide standardization needs.
■ Compact, lightweight unit is easy to handle, convenient totransport, and sets up in seconds.
■ Large, easy-to-read collection chamber numbers andgraduations provide the ultimate in patient drainageassessment.
■ Proven water seal design features maximum knock-overprotection.
■ Blue tint water seal and suction control chambers offerenhanced visibility for tracking patient air leaks and verifyingsuction level.
■ Suction control stopcock provides quieter operation, superioroperating efficiency, and improved evaporation protection.
■ Advanced float valve design provides automatic high negativepressure relief.
■ Filtered manual vent offers optimum protection whenreducing patient pressure.
n Available with in-line patient tube connectors for convenientchange out or rapid in-line ATS bag use.
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Air LeakMonitor
PatientPressureFloat Ball
Swing OutFloor Stand
PatientTubeClamp
PatientConnector
CollectionChamber
Multi-PositionHangers
Easy-to-GripHandle
In-lineConnector
Positive PressureRelease Valve
Manual HighNegativity Vent
SuctionControlChamber
100%LATEX-FREE
Water SealChamber
NeedlelessAccess Port
■ Suction Control StopcockAvailable on most Atrium models, this high quality, largelumen stopcock provides effective control of vacuum to thedrain for more efficient system operation. Simple to use andoperate, it can be adjusted at bedside to increase or decreasesuction control bubbling or simply “quiet down” the chestdrain with soft, gentle bubbling. With Atrium’s uniquesuction control stopcock, multiple drainage units can beconnected to a single suction source, providing effective
control of bubbling foreach. For the first time,a traditional water sealCDU can be safely andconveniently connectedto unregulated vacuumanywhere in the hospital.
■ Advanced Water Seal TechnologyAt the heart of every Atrium water seal chest drain is anadvanced water seal design. Patient air leak assessment andsystem integrity are enhanced with Atrium’s blue tint waterseal and superior knock-over protection. The fully calibratedwater seal also provides more convenient patient pressurediagnostics and features our exclusive automatic highnegative pressure relief. Together with a new, ergonomicallydesigned filtered manual vent, patients now have the utmostprotection from accumulating vacuum pressure.
■ Superior Air Leak DetectionAll Atrium water seal products feature a patient pressure floatball for monitoring changes in intrathoracic pressures. WithAtrium’s graduated air leak monitor at the bottom of thewater seal, intermittent as well as continuous air leaks can bereadily confirmed. When water is added to the water seal,
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the water will turn blue. Thisenhanced visibility ofAtrium’s water seal makesmonitoring patient air leaksquick and easy whenbubbling is present in thegraduated air leak monitor.
■ Proven Float Valve DesignAtrium’s high negativity float valve with its unique controlledrelease action enables any thoracic patient to draw as muchintrathoracic pressure as is required during each respiratorycycle. During prolonged episodes of extreme negativepressure (as with chest tube stripping), Atrium’s controlledrelease system will automatically relieve excessive vacuum toa lower level.
■ Filtered Manual VentAtrium’s filtered manual vent, conveniently located on top ofthe drain, is tamper-resistant, unobtrusive, and easy-to-use.Designed for use when connected to suction, temporarydepression will lower height of water seal column and patientpressure.
■ Convenient System Disconnection AndOptions For AutotransfusionOn models equippedwith in-line connectors,Atrium offers unlimitedflexibility for prescribingpost-op autotransfusionat any time. Thesetamper-resistant,locking patient tubeconnectors provideconvenient systemdisconnection after useor rapid in-line ATSblood bag attachment,when required.
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■ Atrium Product Feature Summary
• Pre-Attached • Quick and easy set up. • No more overfilled or underfilledFunnel water seals. Pull forward and
down. Fill funnel to top, raise toempty water into drain.
• Suction Control • Simple and convenient • Stopcock provides safe andStopcock suction regulation. efficient control for constant
gentle bubbling with eitherregulated or unregulated suction.
• Advanced • Quiet, more efficient • Unique aeration and condensationBlue Tint operation offers maximum rib design reduces vibration andSuction Control evaporation protection. channels water energy. VerifyingChamber suction level is more convenient
with blue tint water.
• Blue Tint • More efficient air leak • Water seal turns blue when Water Seal detection and convenient filled, improves visibility.
monitoring of patient pressure.
• Graduated Air • Fast, easy detection and • Air leak bubbling can range fromLeak Monitor monitoring of patient air 1 (low) to 5 (high) for monitoring
leaks. patient air leak trends.
• Patient Pressure • Instant patient pressure • The small, highly visible float Float Ball verification. ball clearly identifies the height of
the water seal column.
• High Negativity • Advanced design provides • Allows the thoracic patient to Float Valve maximum patient protection draw as much intrathoracic
during deep inspiration and pressure as required to complete gravity drainage. respiration while maintaining the
integrity of the water seal.
• Filtered • Preferred ergonomic • Provides effective manual ventManual Vent design is easy to use and control when lowering height of
offers maximum filter water seal column.protection.
• High Negative • Advanced float valve • Unique valve design offers a Pressure automatically vents controlled release during episodesProtection high vacuum. of prolonged high negative
pressure.
• Positive • Tamper resistant positive • Integral to the system, this valvePressure pressure relief valve automatically prevents tensionProtection automatically protects pneumothorax during accidental
patient from accumulating suction line occlusion.positive pressure.
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Feature Benefit Function
• Autotransfusion • Atrium provides numerous • Fast, convenient ATS bag useCapabilities options for emergency or or continuous ATS via infusion
post-op autotransfusion pump.on demand.
• In-Line • Smooth, low profile design • Connector provides convenientConnector has audible locking system disconnection or fast
mechanism. in-line ATS bag attachment.
• Needleless • In-line fluid removal. No • Connects to any standardAccess Sampling needle necessary. luer-lock syringe.Port
• Patient Tube • Maximum patient protection • Provides secure patient tubeSlide Clamp during patient tube detachment. occlusion during system
disconnection or ATS bag use.Slide clamp design preventsinadvertent closure.
• Collection • Improved collection chamber • Large collection windowChamber design is easier to read. graduations provide fast andGraduations accurate volume assessment.
• Maximum • Fully recoverable water seal • Water seal integrity is preservedKnock-over offers maximum patient during transport and accidentalProtection protection. knock-over, even when connected
to suction.
• Easy-to-Grip • Comfortable design • Makes patient ambulation andHandle facilitates hand-off. patient transport safer and more
practical than before.
• Flexi-Hangers • Accommodates today’s • Flexible hangers (located inside thenewer bed designs. handle) allow drain to be hung from
a single point.
• Swing Out • Secure system placement • Floor stand conveniently swingsFloor Stand during set up or on floor. out for maximum stability, closes
for transport.
• Complete • Atrium produces many • Atrium offers maximum costProduct Line chest drain models for efficiency with superior quality,
hospital-wide standardization, and options for ATS, all withincluding dual collection, a familiar water seal operating pediatric, and numerous system.ATS models.
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Feature Benefit Function
System Set Up■ Open PackageRemove the unit from the outer bag. Atrium chest drains arewrapped in high quality CSR wrap and should be opened fol-lowing hospital approved sterile technique.
■ Requirements For Set UpA maximum of 500cc of water will be required. Determine hos-pital’s protocol for type of water to be used for each model orprocedure (sterile saline or sterile water). Sterile saline is rec-ommended for all continuous ATS applications.
■ Four Step Set UpSwing floor stand open for set up. For models equipped withan in-line connector, move the patient tube clamp closer to thechest drain (next to the in-line connector) for set up conve-nience and patient safety. For those models equipped with asuction control stopcock, it must be ON during system set up.Follow steps 1-4 and refer to each model’s product insert foradditional details concerning system set up, operation, instruc-tions for use, and warnings and cautions.
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■Step 1Fill Water Seal To 2cm LinePosition funnel as shown and add water to top of funnel. Raisefunnel to empty water into water seal to 2cm line.
Once filled, water becomes tinted blue for improved visibilityof air leaks and convenient monitoring of patient pressures.Remove the funnel and discard after use. Do not overfillwater seal above 2cm line. If necessary, remove excess with20 gauge or smaller needle and syringe through grommetlocated on the back.
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■Step 2Fill Suction Control To fill suction control chamber to desired suction pressurelevel (-20cmH2O), remove the tethered vent-plug, pourwater, and replace vent-plug. Once filled, water becomestinted blue.
■Step 3Patient ConnectionRemove patient tube connector cap and insert stepped con-nector into patient catheter(s). Remove or cut off steppedconnector for “Y” connector insertion. If desired, use ofnylon bands around catheter and patient tube connectionswill provide added security and assure an air-tight connec-tion. The chest drain should be connected to the patientprior to initiating suction.
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Indwellingchesttube
■Step 4Applying SuctionAll Atrium chest drainage systems will operate with eitherportable pump or wall suction commonly used for chestdrainage. To apply suction, connect suction source line directlyto the suction control stopcock or suction connector provided.
Connecting To Regulated SuctionWhen applying suction from either a wall regulator or pumpto models equipped with a suction control stopcock, slowlyincrease suction source pressure until constant, gentlebubbling occurs in suction control chamber. Adjust thesuction control stopcock or suction control source as neededto increase or decrease suction control bubbling.
Connecting To Unregulated SuctionWhen applying wall suction without a wall regulator tomodels equipped with a suction control stopcock, turn thestopcock to the OFF position prior to connecting suctionsource to chest drain. Once connected, use the suctioncontrol stopcock to slowly increase suction until constant,gentle bubbling occurs in suction control chamber. Adjuststopcock as needed to increase or decrease suction controlbubbling.
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What To Check DuringSystem Operation
■ Suction Control StopcockAtrium’s suction control stopcock conveniently regulatesvacuum to the chest drain. It provides effective control ofsuction control bubbling and allows efficient use with anyunregulated suction source. The stopcock must be ON forinitial system setup and should not be turned OFF duringpatient use.
■ Verifying System OperationWater seal and suction control chambers must be filled andmaintained to prescribed levels to ensure proper operationand should be checked regularly when used for extendedperiods. Water seal should be maintained at 2cm line andsuction control chamber should bubble gently whenconnected to suction. Adjust stopcock or suction source asneeded to increase or decrease suction control bubbling.
■ Placement Of UnitFor optimum drainage results, always place the chest drainbelow the patient’s chest in an upright position. To avoidaccidental knock-over, it is recommended to swing the floorstand open for secure placement on floor or to hang systembedside with the hangers provided. Atrium’s unique waterseal design provides maximum knock-over protection againstinter-chamber siphoning events, accidental spillover, anddoes not allow unrestricted atmospheric air back to thepatient when kept in an upright position.
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On Off
■ Observing Water Seal For Patient Air LeaksAtrium Ocean™ chest drains offer rapid air leak assessmentand improved visibility due to the tinted water. A patient airleak is confirmed when air bubbles are observed going fromright to left in the air leak monitor.
Continuous bubbling in the water seal air leak monitor willconfirm a persistent air leak.Intermittent bubbling with float ball oscillation will confirmthe presence of an intermittent air leak.No bubbling with minimal float ball oscillation at bottom ofwater seal will indicate no air leak is present.
■ Graduated Air Leak MonitorFor those models with a graduated air leak monitor, air leakbubbling can range from 1 (low) to 5 (high). Air bubblescreate an easy to follow air leak pattern for monitoringpatient air leak trends.
n Sampling Patient DrainageSampling of patient drainage must be in accordance withapproved hospital infection control standards. Selected modelsinclude a needleless luer port on the patient tube connector forsampling patient drainage. Alcohol swab the luer port prior tosyringe attachment (no needle). Fluid samples can also be takendirectly from the patient tube by forming a temporary dependentloop and inserting a 20 gauge needle at an oblique angle.Alcohol swab the patient tube prior to inserting syringe at a shal-low angle. Do not puncture patient tube with an 18 gauge orlarger needle.
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■ Observing Changes In Patient PressureChanges in patient pressure can be determined by observingthe small patient pressure float ball in the calibrated waterseal column. When connected to suction, patient pressurewill equal suction control setting plus the float ball level. Forgravity drainage, patient pressure will equal the float balllevel only.
■ High Negativity Float ValveAtrium’s high negativity floatvalve, with its controlledrelease action, enables anythoracic patient to draw asmuch intrathoracic pressure asis required during eachrespiratory cycle. Duringprolonged episodes of extremenegative pressure, Atrium’scontrolled release system willautomatically relieve excessvacuum to a lower, moredesirable pressure level.
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■ Manual HighNegativity VentTo manually lower the heightof the water seal column orpatient pressure whenconnected to suction,temporarily depress the filtered manual vent, located on top ofthe drain, until the float valve releases and the water columnlowers to the desired level. Do not lower water seal columnwhen suction is not operating or when patient is on gravitydrainage.
■ Positive Pressure ProtectionAtrium’s positive pressure release valve, located on top of thedrain, opens instantly to release accumulated positive pressure.Integral to the system, this advanced valve design is tamper-resistant and offers maximum air flow. Do not obstruct thepositive pressure relief valve.
■ Adding Water To Water SealAs required, additional water may be added using a 20 gauge orsmaller needle and syringe via the grommet on the back. Simplyfill to 2cm line.
■ Adding Water To Suction ControlAs required, additional water may be added to the suctioncontrol chamber by temporarily turning suction source off or byturning stopcock to the OFF position. Add water to desiredpressure level and slowly resume suction or slowly turn thestopcock back on to resume gentle bubbling in the suctioncontrol chamber.
■ To Prescribe Suction Pressure GreaterThan -20cmH2OSuction pressure greater than -20cmH2O can be imposeddirectly by a calibrated wall regulator or portable pump by simplytaping over the vent plug with non-porous tape and readingvacuum pressure directly from regulator or pump. Vacuumpressures greater than -40mmHg are not recommended.
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Do not use when suction isnot operating
■ To Lower Suction Control Pressure SettingTo lower suction pressure setting, turn the suction sourceOFF, remove water by syringe to desired pressure level viathe grommet on the back, and resume suction.
■ Recording Drainage VolumeThe collection chamber incorporates a writing surface witheasy-to-read fluid level calibrations. Please refer to individualproduct for specific calibrations.
■ For Models Equipped With In-Line PatientTube Connector(s)The locking in-line patienttube connector providesconvenient systemreplacement, simple discon-nection after use, or rapidin-line ATS blood bagattachment when required. The in-line connector mustremain securely connected at all times during operation andpatient connection. Do not separate in-line connector priorto clamping off patient tube clamp.
■ Patient Tube ClampThe patient tube clampprovided with in-lineconnector models mustremain open at all timesduring system operation.It is recommended to move thepatient tube clamp next to the in-lineconnector (closer to chest drain) for setup convenience and routine visual check.Do not keep patient tube clamp closed whensystem is connected to patient. Tube clamp must beclosed prior to in-line connector separation.
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Move clampnext toconnector
Keep clampopen at all timeswhen system isconnected topatient
■ Swing Out Floor StandAtrium’s floor stand swings open for convenient system setup and secure placement on floor. It is recommended thatthe floor stand be closed during patient transit or while unit ishung on bed.
■ Multi-Position HangersThe multi-position hangersare easily lifted from insidethe handle. Press hangersinto handle when not in use.
■ Gravity DrainageFor gravity drainage applications, the drain should be placedbelow the patient’s chest in an upright position. Disconnect thesuction source vacuum line from the stepped suction line con-nector or suction control stopcock. For models equipped witha suction control stopcock it is recommended to leave thestopcock in the ON or OPEN position during gravity drainage.
■ System DisconnectionFor models equipped with an in-line connector, close thepatient tube slide clamp prior to disconnecting the chestdrain patient tube from the patient. For maximum patientprotection, clamp off all indwelling thoracic catheters priorto disconnecting the chest drain patient tube from thepatient’s catheter(s).
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Lift touse
Push into lock
Anatomy And PhysiologyReview
■ Anatomy Of The ChestThe chest wall is composed of the ribs, sternum, andthoracic vertebrae and are all interlaced and covered withintercostal muscle to form a semi-rigid structure. The lowerboundary or floor of the thoracic cavity is known as thediaphragm, which is also composed of muscle.
Although the thoracic cavity contains two passagewayswhich are open to the outside environment, the esophagusand trachea, the cavity itself is an enclosed structure. Theinterior of the thoracic cavity can be divided into three distinctareas: the mediastinum and two separate chambers for eachlung. The superior mediastinum consists of soft tissuewhich encloses the esophagus, trachea, heart, aorta, andother major vessels. The mediastinum acts as a flexiblepartition which extends from front-to-back and top-to-bottomof the central portion of the chest.
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Right lungcavity Diaphragm
Mediastinalcavity
Left lungcavity
Chest wall
Trachea
The inside of the rib cage is lined by a membrane called theparietal pleura while the lungs are covered by anothermembrane called the pulmonary or visceral pleura. Undernormal conditions, these two pleural surfaces slide againsteach other allowing the lungs to expand and contract. Thesetwo surfaces are closely held to one another, being separatedonly by a very thin film of lubricating fluid secreted by thepleura, called pleural fluid.
■ Why The Lungs Are ExpandedA principal factor which keeps the visceral and parietalpleurae together and not separating is vacuum, commonlyreferred to as negative pressure. This negative pressure, orvacuum, is always present during normal respiration with themembranes closely intact under normal conditions. Thepresence of negative pressure between these twomembranes is what helps hold the visceral pleura in closecontact with the parietal pleura at all times. Hence, negativepressure or vacuum around the outside of the elastic lung iswhat keeps the lung in a fully expanded position, counteract-ing the lung’s normal tendency to shrink in size.
If air, fluid, or blood were to enter the space between thesetwo membranes, the space created is known as a pleuralspace and is an abnormal occurrence. When this occurs,the lungs can no longer fully expand with each inspirationand intense pain results, inhibiting the voluntary effort ofbreathing.
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Parietalpleura
Pleuralspace
Visceralpleura
■ The Mechanics Of BreathingRespiration is the cycle of inspiration and expiration in whichair moves in and out of the lungs due to changes in pressure.When the diaphragm is stimulated by the phrenic nerve, itcontracts and moves downward. With the help of theexternal intercostal muscles, the rib cage moves up and out.The lung itself expands because of the movement of thediaphragm and the chest wall. The surface tension of thepleural fluid together with the naturally occurring vacuumpressure induced by the pulling action of the diaphragm iswhat actually holds the pleural membranes together, thuskeeping the lungs fully expanded.
Under normal conditions,there is always negativepressure in the pleuralcavity. The degree ofnegativity, however,changes duringrespiration. Duringnormal inspiration,intrapleural vacuumpressure is approximately-8cmH2O, while duringexpiration the vacuumpressure falls to -4cmH2O.With deep inspiration,intrapleural vacuumpressures can be evenmore negative.
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Inspiration–8cmH2O
Expiration–4cmH2O
Why Water Seal CDU’sAreUsed
■ Clinical Needs For Chest Tube DrainageWhen the chest wall is opened either by surgery or chestinjury, the in-rush of air causes the vacuum in the patient’spleural cavity to escape and atmospheric air to enter theintrapleural space. Since the normal negative pressure orvacuum is no longer present, the lungs collapse as theydepend upon this negativity or vacuum to stay fully expandedup against the inside of the chest wall. When air enters orbecomes trapped inside the chest causing a pleural space,the lungs cannot fully expand, and the patient will experiencedifficulty in breathing. This condition is known as apneumothorax. This is a frequent occurrence after allthoracic and cardiac surgeries, as well as with most chestwall injuries. Very often there is a combination of both airand blood present in this abnormal space, causing a similareffect on breathing. When blood collects in the patient’spleural space, it is known as a hemothorax and when there isthe combination of both blood and air, it is known as ahemopneumothorax.
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Pneumothorax
Hemopneumothorax
Tension pneumothorax is a more serious complication thatcan develop when air continues to leak from a hole in thelung directly into the pleural space and has no way to escape.As more and more air accumulates in the pleural space,pressure within this space rises significantly. If the pressurewithin builds up enough, it causes a mediastinal shift, whichmeans that the entire mediastinal area, including the heartand other structures, can be pushed toward the unaffectedside. This reduces the size of the unaffected lung chamber,making it very difficult to breathe. A mediastinal shift canalso be significant enough to collapse the unaffected lung toa measurable degree and interfere with normal heart activity.When the compressed lung becomes collapsed as a result ofa tension pneumothorax condition, a life-threatening situationdevelops which requires immediate attention. Early signs ofmediastinal shift may include an over-expanded chest,shallow gasping respiration, a shift of the trachea in thesuprasternal notch, and changes in arterial pulse. Any one orall of these signs require prompt attention and emergencyaction by the nurse and/or physician. Normally, this wouldbe accomplished with a procedure known as a thoracostomy.
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Tension pneumothorax,mediastinal shift
Other conditions in the pleural cavity that may require chestdrainage intervention are pleural effusion and empyema.Pleural effusion is the accumulation of fluid within the pleuralcavity. The presence of lymph fluid is called chylothorax andis often clear, serous fluid. Empyema is a pleural effusionthat involves purulent material in the pleural cavity and isoften caused by pneumonia, lung abscess, iatrogeniccontamination of the pleural cavity, or injury.
Mediastinal drainage is routinely required after all heartsurgeries, sometimes including pleural drainage. Mediastinaldrainage is required to prevent the accumulation of blood andclots from taking up space in and around the pericardiac sac.If blood were left to accumulate in the mediastinal cavity, itwould cause cardiac tamponade, resulting in cardiac distressand death.
The physician’s prescribed treatment for any of these clinicaldrainage situations are:
1. To remove the fluid and air as promptly as possible.
2. To prevent evacuated air and fluid from returning into the chest cavity.
3. To expand the lungs and restore the negative pressure in the thoracic cavity back to its normal level.
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Pleural effusion
Problems To Check ForDuring CDU UseVery often, potential problems can be avoided by routinelychecking the patient, tube connectors, and drainage systemat regularly scheduled intervals. Listed below are many ofthose common problems that can be easily corrected:
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n clot in chest tube insidepatient
n clot in the patient tuben dependent loop inpatient tube with fluid
n kink in patient tube frombed rail or patient position
n partial dislodgement ofcatheter from patient
n partial disconnection ofpatient tube from chesttube connector
n overfilled water seal(water is above 2cm line)
n in-line connectors notproperly secured
n patient tube clamp maybe closed
n floor stand is not fullyopened
n chest drain is not uprightn chest drain is notpositioned sufficientlybelow patient’s chest
n suction control isnot bubbling due toinsufficient suctionregulation or poorconnection
n suction control isbubbling too vigorously
Chest Tube Placement
■ Chest Tube InsertionTo facilitate air and fluid evacuation post surgically, thesurgeon will insert a catheter or thoracotomy chest tube sothat the chest tube eyelets are located inside the chest wall.The surgeon will usually suture the catheter loosely in placeto facilitate removal later on. Frequently two catheters areinserted, in which case one is placed near the apex to removeair while the other is placed in the lower part of the chest toremove any pooled blood.
Thoracotomy chest tubes are normally flexible, kink resistant,clear catheters which are inserted through the chest wall via asmall incision. A tight intercostal fit is preferred to minimizesmall bleeders around the catheter and to maintain an air-tight seal. A radiopaque stripe helps the clinician identifycatheter placement and location of the “catheter eyes” duringX-ray for maximum drainage efficiency.
8FR-12FR Infants, young children Typical16FR-20FR Children, young adults Chest Tube24FR-32FR Most popular adult sizes Sizes36FR-40FR Larger adult sizes
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Commoninsertion sitefor fluid
Commoninsertionsite forair
■ Chest Tube Nursing ResponsibilitiesAfter chest tube insertion, the connector end of the catheteris cut to length and the chest drain stepped connector isinserted. Such connections are often secured with nylonbands for added security and to assure an air-tight tubingconnection.
Since two or more indwelling chest tubes are frequentlyattached to a single chest drain via a “Y” connector set up, itis important to ensure that all indwelling catheters areproperly tailored so as to not kink.
It is important to check the chest tube connections forsigns of air leaks, such as “hissing” sounds or bubblingin the water seal. Also check the chest tube dressing andcondition of the tube itself, such as position or clotting inthe tube. If a tube accidentally pulls out, the insertion siteshould be quickly sealed with a petroleum gauze dressingto prevent air from entering the pleural cavity. Thephysician should be notified to assess the patient’scondition and to determine whether or not a new tube willneed to be inserted bedside.
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Bands for added security
Incorrect Correct
Troubleshooting Guide
How do I confirm my patient has an air leak whenthere is:
■ No bubbling in the water seal?
If there are no air bubbles observed going from right toleft in the air leak monitor, there is no patient air leak.In order to confirm that your patient’s chest catheter(s)are patent, temporarily turn suction off and check foroscillation of the patient pressure float ball in the waterseal column coinciding with patient respiration.
■ Bubbling present in the water seal?
Whenever constant or intermittent bubbling is presentin the water seal air leak monitor, this will confirm an airleak is present. Oscillation of the patient pressure floatball at the bottom of the water seal without bubblingwill indicate no apparent air leak. Bubbling from rightto left must be present to confirm an air leak. Todetermine the source of the air leak (patient or catheterconnection), momentarily clamp the patient tubeclose to the chest drain and observe the water seal.If bubbling stops, the air leak may be from the catheterconnections or the patient’s chest. Check the catheterconnectors and patient dressing for a partiallywithdrawn catheter. If bubbling continues aftertemporarily clamping the patient tube, this will indicatea system air leak requiring system replacement.
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What does it mean when the small float ball islocated at the bottom of the water seal column?
If the small float ball is located and oscillating at thebottom of the water seal column with no bubbling,there is no apparent patient air leak. However, the waterseal should be carefully monitored for the presence ofan occasional or intermittent air leak.
How do I lower the water seal level?
Changes in your patient’s intrathoracic pressure will bereflected by the height of the water in the water sealcolumn. These changes are usually due to mechanicalmeans such as milking or stripping patient drainagetubes, or simply by deep inspiration by your patientafter all air leaks have subsided. If desired, the heightof the water column and patient pressure can bereduced by temporarily depressing the filtered manualvent located on top of the drain, until the float valvereleases and the water column lowers to the desiredlevel. Do not lower water seal column when suction isnot operating, or when patient is on gravity drainage.
What happens when the water rises to the top of thewater seal float valve?
The water seal column is a diagnostic manometer formonitoring your patient’s intrathoracic pressure. Whenintrathoracic pressures increase, causing the water torise to the top of the water seal float valve, the ballfloats up and “seats” up against a curved valve seat.This valve seat has been carefully engineered to allow a
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certain amount of waterto pass through it duringa precise amount of time.When vacuum pressuresgreater than -20cmH2O ongravity or -40cmH2O onsuction occur for anextended period of time,water will pass throughthe valve and float valveto allow the water seal torelease automatically. Thebenefit to Atrium’s controlled release design is thatduring normal or deep inspiration, the float valve willfloat up and down with each respiratory cycle, notallowing the water seal to release. This enables thoracicpatients to draw as much intrathoracic pressure as theymay require during each respiratory cycle.
Is it normal for the patient pressure float ball tofluctuate up and down (tidal) near the bottom of thewater seal column?
Yes. Once your patient’s air leak is resolved, you willgenerally observe moderate tidaling in the water sealcolumn. Increases in intrathoracic pressure will causethe water level to rise (the ball rises) during patientinspiration and will lower or decrease (the ball drops)during expiration. This diagnostic tool will help toconfirm patency of your patient’s catheter(s).
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What happens when:
n There is no bubbling in the suction control chamber?
Check to be sure the suction tubing is connected to thechest drain and to the wall regulator and the suctionsource is turned on. Adjusting Atrium’s suction controlstopcock is required for constant gentle bubbling.
n There is vigorous bubbling in the suction control chamber?
Vigorous bubbling causes quicker evaporation andproduces excessive noise. Constant, gentle bubbling isall that is required to impose the prescribed amount ofsuction. Available on all models, Atrium’s suctioncontrol stopcock located on the suction tubing, can beused to adjust bubbling. The suction source regulatorcan also be adjusted to turn suction control bubbling upor down.
How can I connect multiple chest drains to onesuction source easily?
With Atrium models equipped with a suction controlstopcock, connection of two or more chest drains to acommon suction source is made easier. Place a 1/4" x1/4" x 1/4" Y connector on the wall suction tubing. Cutthe drain suction tubing where indicated in Illustration 1.Now invert the cut sections of suction tubing as shownin Illustration 2 and insert them into the suction tubingremaining on the chest drain.
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Now you have two open ends of suction line tubing forthe Y connector to be placed. Turn on suction andadjust Atrium’s suction control stopcock on each drainto achieve constant, gentle bubbling with each.
Should the suction control stopcock be turned off forgravity drainage or for patient transport?
No. The patient is protected two ways: first by the one-way valve created by the water seal to maintain thedesired patient vacuum pressure, and second, thepatient is protected by the integral positive pressurevalve in the event the stopcock is turned off. It is notnecessary to turn off the stopcock, clamp, or cap the
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Illustration 1.
Illustration 2.
Insert
Insert “Y”
Cut chest drain suctionline and insert stopcockinto open tubing
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suction line during gravity drainage or patient transport.Both the water seal and the positive pressure valveprovide maximum patient protection when either thesuction line or stopcock remain open or closed.
Should the manual vent be used during gravitydrainage?
No. It is not recommended to depress the manual ventduring gravity (no suction) drainage.
If the chest drainage system has been knocked over,can I use it and what should I do?
After a chest drainage system has been knocked over,set it upright and immediately check the fluid levels ofthe water seal and suction control chambers for propervolumes. Atrium provides convenient, self-sealingdiaphragms for access by a 20 gauge or smaller needleand syringe to adjust the water level in each chamber, ifrequired. Alcohol swab the needle access area andaspirate any overfill that may have occurred. If the waterseal or suction control chambers have an inadequatefluid level, simply replace the lost volume. If a significantamount of blood has entered the water seal, it may beadvisable to change the system for a new one.
How do I dispose of the system?
Disposal of system and contents must be in accordancewith approved hospital infection control standards.
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Notes
CUSTOMER SERVICEIf a question or need arises for customer service, productinformation, or to request inservice educational material,we invite you to call or FAX Atrium’s hotline anytime.
In the U.S.A. 1-800-528-7486Outside the U.S.A. 603-880-1433FAX 603-880-6718www.atriummed.com
© Atrium
Medical Corporation 2010 Made and printed in U.S.A. 10/10 342263K
