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M & M. Garrett Post, MD PGY-2 Emory Family Medicine Residency Program May 8, 2008. Lung Physiology. Lung tissue – well aerated organ, soft and compliant lined by visceral pleura. Two chambers separated by soft mediastinum.

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M & M

Garrett Post, MD

PGY-2

Emory Family Medicine Residency Program

May 8, 2008


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Lung Physiology

  • Lung tissue – well aerated organ, soft and compliant lined by visceral pleura.

  • Two chambers separated by soft mediastinum.

  • Negative pressure of -5 cm H20 in conjunction with diaphragm and rib movement promotes expansion.


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Pleurovac Design


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Pleurovac Design

  • An underwater seal is used to allow air to escape through the drain but not to re-enter the thoracic cavity.

  • The drainage bottle should always be kept below the level of the patient, otherwise its contents will siphon back into the chest cavity.

  • The air outlet of the underwater seal may be connected to moderate suction (-20cm water) to assist in lung re-expansion. This is more important in the presence of an air leak.


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Physiology


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What is an air leak?

  • Persistent bubbling of air through the water indicates an air leak from the lung.


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Etiology

Patient Pathology

  • Tracheobronchial disruption

  • Parenchymal injury or tear

  • Esophageal perforation

  • Unsealed chest wall disruption (i.e. open pneumothorax or sucking chest wound)

    Tube Pathology

  • Leak at insertion site

  • Proximal hole in tube outside chest wall

  • Perforation of chest tube

  • Poor seal at connection of tube and pleurovac tube

    Pleurovac Pathology

  • Improperly prepared apparatus

  • Broken apparatus


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What to do?

  • Call Surgery

  • Inspect and correct any obvious defects in setup of pleurovac. You may chose to replace the entire system and do it yourself.

  • Inspect all connections between the circuit and between the tube and the pleurovac. Remove dressing and tape to make all anatomy and apparatus visible and ensure an airtight seal.

  • Inspect the chest tube insertion site. An xray may be beneficial in obese patients to ensure perforations in the CT are within the chest cavity.

  • Once you have completed these steps, you may clamp the tubing beginning proximally or closest to the pleurovac to evaluate for a leak. If the leak persists once clamped, the malfunction can be isolated proximal to clamping.


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Sealing an air leak

  • Fix Apparatus Malfunction

  • Surgery

  • Pleurodesis

    • doxycycline

    • talc slurry

    • autologous ‘blood patch’


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Persistent Air Leak - ACCP Consensus Statement

  • Continue observation for 4 days to assess for spontaneous closure of bronchopleural fistula. If an air leak persists longer than 4 days, evaluate the patient for surgery to close the air leak and perform a pleurodesis procedure to prevent pneumothorax recurrence (Very Good Consensus). Thoracoscopy is the preferred management procedure (Very Good Consensus).

  • Use of an additional chest tube or bronchoscopy in an attempt to seal endobronchial sites of air leakage is not indicated (Very Good Consensus).

  • Except in special circumstances where surgery is contraindicated or a patient refuses surgery, chemical pleurodesis should not be used in the management of most patients (Very Good Consensus). If chemical pleurodesis is performed, doxycycline or talc slurry are the preferred sclerosing agents (Good Consensus).

    Via website 2008


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