Can someone please explain how chest tubes work or provide a link to a good video explanation. It’s one of those questions that at this point I’m too embarrassed to ask. Also any tips and tricks are appreciated.
Edit: thanks for the great responses. Much appreciated.
Posted Mar 26, 2019, 12:34 PM UTC · edited
WTF IS WATERSEAL
Think about it like this, a toilet waterseals your house from the sewer.
Water seal just means it’s not on suction. Literally just have a tube there with no vacuum and “suction” is provided by gravity. If a pneumothorax reoccurs on water seal, you need to go back on suction.
Technically it actually means it's connected to a functional one way valve via wate immersion, I.e. A Pleurivac or something similar. You could have a chest tube clamped or connected to a Heimlich valve and that wouldn't be considered water seal.
Right around 9:30, this video illustrates the Atrium pretty well. Confusing af until you see specifically what each chamber does. Hope this helps!
This was an amazing explanation! The analogy of the soda cup was particularly helpful. Thanks for the video!
Have you checked out the uptodate page on chest tube management. In addition to medical conditions and drugs, they also have pretty nice write ups on a number of common medical procedures as well as chest tube management and other such things. Generally pretty good starting point, though if you’re still stuck let me know.
If I recall, NEJM and/or JAMA have some good procedural videos with step-by-step guides. Youtube also has some good stuff.
The placement is slightly variable by provider preference and also clinical scenario (e.g., someone who is coding due to tension probably gets a quick and dirty prep rather than slow and controlled with pretty draping on a less emergent case.)
They provide a constant which sucks out excess fluid from the chest cavity.
Water seal provides a constant suction by using gravity and water to allow fluid to drain. Think of siphoning gas into a Jerry can. Wall suction provides additional negative pressure.
Last part is checking for leaks by having the patient cough. I don't now the physics of this, I'm sorry. But a leak will cause air bubbles to appear in water seal window.
Don’t think I’ve ever seen a chest tube to liws. I’ve always just hooked up to constant wall suction and the atriums we use have a limiter to change the amount of suction you want or need.
ah shit i was thinking of a damned NG
When it comes to chest tubes, there is a lot of religion and less science. Know that going in, and you're going to be better off. We place chest tubes for 2 general reason - drain air from the pleural space or drain fluid (usually blood but sometimes effusions) from the pleural space. The concept is simple, it's a small hose that goes in the pleural space and whatever is in there comes out.
But how can you be sure that what's in comes out, and you aren't putting atmospheric air in? There are 2 things we can do. Firstly the chest tube is connected to a collection container (atrium/oasis , pleurevac etc). These provide 2 options: water seal and suction. You connect a wall suction tubing to the collection chamber and you can apply continuous negative pressure to the tube. This is helpful if you have a large pneumothorax that continues to re-accumulate (though often once you drain the air the lung will abut the chest wall on tamponade any continued pneumothorax). If you have a continuously bleeding vessel (though if this is the case they will need to go to the OR).
Water seal (the other option) is a way of ensuring that your chest tube is connected to a 1-way valve. To place a chest tube on water seal all you really need to do is pull the suction tubing off the collection device. You can verify that a chest tube is on water seal by looking at the indicator window (most will have something that expands in the presence of negative pressure to verify you are actively applying suction (see this pic) notice how in the picture the orange indicator fills the window? This indicates the atrium is to suction (obviously in this picture there is no suction applied but its a product image and not a chamber actually being used).
Water seal is just that. When you set up an atrium you fill it with water that comes in the kit. This is used to create a 1 way valve. It prevents atmospheric air from traveling in reverse through the chest tube and creating a pneumothorax while allowing air/liquid in the chest to drain.
We use water seal as a sort of test to see how well the patient will tolerate removal of the tube. Let's say you had a pneumothorax, you place a chest tube and drain the air. You keep it on suction for a specific amount of time (again, religion not science. Many people who manage chest tubes have their way of doing it, but don't let them convince you that their way is the way). Then you want to know if it's safe to pull it? After all a large pneumothorax may re-accumulate once the tube is removed that would necessitate another tube which will make your patient's unhappy. So instead you simply turn off the suction and place the chest tube to water seal. Wait a few hours, snap a chest X-ray and see what the chest looks like. If it looks good you can pull the tube. If you're still putting out blood/fluid then keep it in (again depending on how much and why it's putting out fluid). Some thoracic patient's will have pleur-x tubes in for awhile and can manage them at home, but for hospital purposes this is a general guide that should get you where you need.
Once you pull a tube snap a chest X-ray later on to look for re-accumulation of whatever. Many people say 4 hours, some say overnight....religion, not science.
Is your chest tube working? When you're rounding and looking at a chest tube you're looking for a few things. Is there an air leak? You will notice this in the fluid chamber at the bottom of the collection device - it will be in the form of continuous or periodic bubbling. You can tell the strength by the frequency the bubbles are drained or by looking at the numerical grading scale on the water chamber. Air leak indicates there is either a problem in your tubing/collection chamber (possibly), or that you still have pneumothoax that is periodically being evacuated. Next look to see if it is tidaling. There is a small ball floating next to the water chamber. With inspiration/expiration you will often notice a slight change in the height of the ball that corresponds with changing intrathoracic pressure. This is good and lets you know your chest tube is functioning normally. If it isn't tidaling, and isn't draining the next question should be - can we pull the tube? If the ball is at the very top of the graduated chamber then there is a pressure relief valve on the top of the collection kit. If it is too low you can physically strip the tubing to change intrathoracic pressure to raise the level - but avoid this unless you really understand what and why you are doing it.
Finally, there are some great videos aimed at nursing, and can be kind of long. But as far as I'm concerned they are must-watches. They talk about setting up the atrium (most common collection device). It's definitely a sales pitch for the product, but it really does clarify things. I hope this helps.
Atrium Video. (you have to tolerate their pronunciation of "sontometers" for centimeters, which just kills me.
Also, I highly recommend reading the instructions that come with the atrium, or pulling them off the website.
Any other questions let me know!
Is saying "sontimeters" as prevalent as some of my lecturers made it out to be? Our surgery professor says it and a few others. I'd rather not be in medicine than to hear that used regularly...
Thank you for saying this. It’s big in radiology too, although it tends to be the older attending‘s.
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This was such a good explanation! You do any other educational stuff?
Thanks! I haven’t done anything else, just saw this post this morning and thought I’d contribute.
Chest tubes are one of those things that have a lot of confusion to their practice (probably by the significant practice variation of those who place and manage them), and I like it when things are demystified. When it comes down to it, chest tubes are simple devices, I’m convinced we’ve made them more difficult to understand for our own egotistical benefit haha.
It’s all about job security.
I believe that 100%. Also, if you do any more write-ups of confusing topics in medicine I would like to read them. You're good at explaining things to lowly PGY-2's such as myself.
Yes, agreed. Please let us know. I need more of these types of clear, practical explanations for intern year.
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This was excellent. I have nothing to add. Great summary
You’re my hero. That’s a great explanation. Thank you for taking the time to write all that!
This was the most incredible explanation of chest tubes I’ve ever seen. I didn’t understand them at all until now. Thank you so, so much. You deserve all the reddit gold and more!