Thoracic Drainage
Thomas Malfait M.D.
thomas.malfait@uzgent.be
Endoscopische eenheid UZ Gent – 3K12 IE
Longziekten UZ Gent – 7K12IE
© 2010 Universitair Ziekenhuis Gent
Pleural Procedures
1.
2.
Thoracocentesis
Chest drain insertion
BTS Pleural Disease Guideline 2010 - Pleural procedures and thoracic ultrasound
Thorax 2010;65(Suppl2):ii61eii76.doi:10.1136/thx.2010.137026
© 2010 Universitair Ziekenhuis Gent
Interactivity
Voting system
Please return controllers (€25/pp)
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I will return my controller
A.
B.
Yes
No
85%
© 2010 Universitair Ziekenhuis Gent
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N
Ye
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15%
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I speak
A.
B.
C.
88%
French
Dutch
Other
11%
© 2010 Universitair Ziekenhuis Gent
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Chest Drain Insertion
© 2010 Universitair Ziekenhuis Gent
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Goal
•
•
•
•
Understand basic princples of thoracic drainage and
apply them in real life
Recognition of most widespread systems and apply
basic pricples on these systems
Not every detail will be discussed
Not all drainage systems will be discussed
© 2010 Universitair Ziekenhuis Gent
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I work at
49%
A.
Hospitalisation internal
B.
Hospitalisation surgical
23%
Policlinic
11%
Other
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© 2010 Universitair Ziekenhuis Gent
ER
F.
3%
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E.
3%
Po
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D.
11%
Ot
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C.
Student
D.
Physiotherapist
M
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Nu
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0%
© 2010 Universitair Ziekenhuis Gent
1%
1%
ist
Medical doctor
th
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B.
Ph
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Nurse
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A.
97%
St
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I ‘m
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Thoracic drainage :
A.
Huh ????
B.
As student but nothing more
C.
Low exposure and not
37%
34%
25%
confident
Regular exposure but not
4%
confident
© 2010 Universitair Ziekenhuis Gent
co
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...
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uc
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ex
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Hu
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confident
Re
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Much exposure and
??
??
E.
0%
xp
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D.
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Agenda
1.
2.
3.
Pleural anatomy and (pathofysiology)
Thoraxdrainage
Different systems up close
© 2010 Universitair Ziekenhuis Gent
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Agenda
1.
2.
3.
Pleural anatomy and (pathofysiology)
Thoraxdrainage
Different systems up close
© 2010 Universitair Ziekenhuis Gent
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Pleural anatomy and pathofysiology
Knowledge of basic principles = fundamental
© 2010 Universitair Ziekenhuis Gent
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Pleural anatomy and pathofysiology
Pleural space = real space between parietal and visceral
pleurae.
10 à 20 µm wide
Around the entire lung
Visceral = around lungs
Parietal = against thoracic wall
© 2010 Universitair Ziekenhuis Gent
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Pleural anatomy and pathofysiology
Electronmicroscopy pleural
space
–
–
–
© 2010 Universitair Ziekenhuis Gent
PP : parietal pleura
VP : visceral pleura
PS : pleural space
15
Pleural anatomy and pathofysiology
Continuous negative pressure in the pleural space.
- 2cmH20 (=vacuum)
Sum of lung recoil, thoracic wall strengths, oncotic en
hydrostatic pressures.
Visceral pleura sucks to the parietal pleura
When thoracic wall moves outside (inspiration) lung is opened
and air is sucked into the lungs = active process.
When thoracic wall relaxes (expiration) lung recoils and air is
pushed outside = passive process
© 2010 Universitair Ziekenhuis Gent
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Pleural anatomy and pathofysiology
http://people.eku.edu/ritchisong/301notes6.htm
© 2010 Universitair Ziekenhuis Gent
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Pleural anatomy and pathofysiology
1.
2.
Air in the pleural space = pneumothorax
Fluid in the pleural space = pleural fluid
© 2010 Universitair Ziekenhuis Gent
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Pleural anatomy and pathofysiology
Pneumothorax
Every condition when air is in the pleural space
Detachment between parietal and visceral pleurae.
Less expansion of the lung
Tension pneumothorax :
Valve principle
Whole unilateral thoracic cavity filled with air and extra air is
pushed in – high pressure on mediastinum and shift of
mediastinum hemodynamic instability
Primary pneumothorax  Secondary pneumothorax.
Underlying comorbidity
© 2010 Universitair Ziekenhuis Gent
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Pleural anatomy and pathofysiology
Pleural Fluid
Pleural fluid
absorption
Pleural fluid
production
© 2010 Universitair Ziekenhuis Gent
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Pleural anatomy and pathofysiology
Systemic circulation
© 2010 Universitair Ziekenhuis Gent
Pulmonal circulation
22
Pleural anatomy and pathofysiology
Transudative Pleural Effusions
Congestive heart failure
Pericardial disease
Hepatic hydrothorax
Nephrotic syndrome
Peritoneal dialysis
Urinothorax
Myxedema
Fontan procedure
Central venous occlusion
Subarachnoid-pleural fistula
Veno-occlusive disease
Bone marrow transplantation
Iatrogenic
+/- 70
Exudative Pleural Effusions
Neoplastic diseases
Metastatic disease, Mesothelioma, Primary effusion lymphoma, Pyothorax-associated lymphoma
Infectious diseases
Pyogenic bacterial infections, Tuberculosis,Actinomycosis and nocardiosis, Fungal infections, Viral infections,
Parasitic infections
Pulmonary embolism
Gastrointestinal disease
Esophageal perforation, Pancreatic disease, Intra-abdominal abscesses, Diaphragmatic hernia, Post-abdominal
surgery
Collagen vascular diseases
Rheumatoid pleuritis, Systemic lupus erythematosus ,Drug-induced lupus, Immunoblastic lymphadenopathy,
Sjögren's syndrome, Churg-Strauss syndrome, Wegener's granulomatosis
Post-cardiac injury syndrome
Post-coronary artery bypass surgery
Asbestos exposure
Sarcoidosis
Uremia
Meigs' syndrome
Ovarian hyperstimulation syndrome
Yellow nail syndrome
Drug-induced pleural disease
Nitrofurantoin Dantrolene Methysergide Bromocriptine Procarbazine Amiodarone
Trapped lung
Radiation therapy
Electrical burns
Iatrogenic injury
Hemothorax
Chylothorax
© 2010 Universitair Ziekenhuis Gent
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Agenda
1.
2.
3.
Pleural anatomy and (pathofysiology)
Thoraxdrainage
Different systems up close
© 2010 Universitair Ziekenhuis Gent
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Thoracic Drainage
1.
2.
3.
4.
5.
6.
7.
8.
Pre – Procedure Preparation
Indications
Complications
Equipment
Patient position and site of insertion
Analgesia, sedation and local anaesthesia
Insertion technique
Chest drain management
© 2010 Universitair Ziekenhuis Gent
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Pre – Procedure Preparation
Pleural procedures should not take place out of hours
except in an emergency
© 2010 Universitair Ziekenhuis Gent
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© 2010 Universitair Ziekenhuis Gent
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Pre – Procedure Preparation
Pleural procedures should not take place out of hours
except in an emergency
Pleural procedures should be performed in a clean area
using full aseptic technique
Written consent should be obtained for chest drain
insertions, except in emergency situations
Non-urgent pleural procedures should be avoided in
anticoagulated patients until INR < 1.5
© 2010 Universitair Ziekenhuis Gent
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Pre – Procedure Preparation
Healthy subjects : no need for lab testing
Patients at risk : lab testing
Hematologic, oncologic
Thrombocytes - clotting
INR < 1.5 or antico stop > 5 days
LMWH : stop > 12hrs
NOAC’s : stop > 24 hrs
© 2010 Universitair Ziekenhuis Gent
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Pre – Procedure Preparation
Pre-drainage risk assessment
Cave emphysema – cave adjacent lung
Imaging available
Marking side
Equipment available and checked
Time – out procedure !!!! SOP !!!
© 2010 Universitair Ziekenhuis Gent
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Indications
1.
Pneumothorax*
•
•
•
•
In any ventilated patient
Tension pneumothorax after needle relief
Persistent or recurrent pneumothorax after simple aspiration
Large secondary spontaneous pneumothorax in patients > 50 years
2.
Malignant pleural effusions + pleurodesis*
3.
Empyema and complicated parapneumonic pleural effusion*
4.
Traumatic heamopneumothorax
5.
Post-surgical
•
Thoracotomy, oesophagectomy, cardial surgery)
© 2010 Universitair Ziekenhuis Gent
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Complications
Pain
Intrapleural infection
Wound infection
Drain dislodgement
Drain blockage
Drain related visceral injury
© 2010 Universitair Ziekenhuis Gent
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Equipment
Sterile gloves and gown
Needleholder
Mask and hat
Instrument for blunt dissection
Skin antiseptic solution
iodine
chloorhexidine in alcohol
Large bore drain insertion
Guidewire and dilatators
Small bore – Seldinger technique
Sterile drapes
Chest tube
Gauze swabs
Fitting connecting pieces
Syringes + needles (21-25 G)
Connecting tubing + clamp
Local anaesthetic
Closed drainage system
eg lidocaïne 1% of 2%
Scalpel + blade
Suture
Underwater seal – sterile water
Electronic seal - drainage
Dressing
Non - resolving : Silk 0 - 1
© 2010 Universitair Ziekenhuis Gent
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© 2010 Universitair Ziekenhuis Gent
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Equipment : small bore drain - seldinger
© 2010 Universitair Ziekenhuis Gent
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Equipment : large bore drains
© 2010 Universitair Ziekenhuis Gent
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© 2010 Universitair Ziekenhuis Gent
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Site of insertion
I
Angulus Ludovici Sternum
II
III
IV
V
© 2010 Universitair Ziekenhuis Gent
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Site of insertion (1) : triangle of safety
Axilla Base
Lateral edge pectoralis major
Latissimus dorsi
5th intercostal space
© 2010 Universitair Ziekenhuis Gent
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Site of insertion (2) : 2nd IC - midclavicular
Can J Rural Med 2009; 14 (4)
© 2010 Universitair Ziekenhuis Gent
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Site of insertion
© 2010 Universitair Ziekenhuis Gent
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Site of insertion
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Analgesia, sedation, local anaesthesia
Inserting chest drain = painful !!!
50% pts : 9-10 VAS
Analgesia + sedation :
No established evidence – cave operators unfamiliarity
Cfr local SOP
Local aneasthesia
Lidocaïne 1% - particular attention to the skin,
periostium and pleura
Up to 3mg/kg
Epinephrine aids hemostasis + localise anaesthesia
Not been studied in this context
© 2010 Universitair Ziekenhuis Gent
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Inserting technique
Confirming site of insertion
Control site
‘Drawing’
Prior to insertion expected pleural contents (air or fluid)
should be aspirated
Usually while administering local anaesthesia
If this not possible → stop procedure
Further imaging (eg US) might be helpful
© 2010 Universitair Ziekenhuis Gent
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Inserting technique : Small bore
Needle into pleural space with aspiration (air / fluid)
Guidewire is passed through the needle
Needle is removed – small incision next to te wire
Dilator over the wire – twisting action – gentle, no
substantial force – no more then 1 cm into pleural cavity
Series of enlarging dilators up to the size of the drain
Drain over the wire - aiming :
Apical : pneumothorax
Posterobasal : pleural fluid
© 2010 Universitair Ziekenhuis Gent
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1
2
3
4
http://elearning.scot.nhs.uk:8080/intralibrary/open_virtual_file_path/i287n2751048t/chestdrains_18.htm
© 2010 Universitair Ziekenhuis Gent
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Inserting technique : Large Bore
Needle into pleural space with aspiration (air / fluid)
Local aneaesthesia
Incision (Ø drain) – alignement with intercostal space
Blunt dissection using Spencer – Wells clamp or similar
Gently spreading
No substantial force
(No) trocars !!!
Air : aiming apical
Fluid : aiming posterobasal
Clamp drain
© 2010 Universitair Ziekenhuis Gent
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Inserting technique : Large Bore
© 2010 Universitair Ziekenhuis Gent
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1
2
3
4
http://elearning.scot.nhs.uk:8080/intralibrary/open_virtual_file_path/i287n2751048t/chestdrains_18.htm
© 2010 Universitair Ziekenhuis Gent
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Insertion technique : sutures and securing
Prevention of kinking at skin surface
Dressing under drain
Anchoring suture not to firm
Mattress suture
Prevention of traction
Omental taping
Commercially available dressings
Patient comfort
Anterior
© 2010 Universitair Ziekenhuis Gent
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Main concern – dressing :
dr
a
in
ie
f
he
of
t
ng
to
n
tio
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Co
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s
1%
11% 9%
nk
i
D.
Re
l
C.
Ki
B.
Only white gauzes
Connection to
aspiration
Pain Relief
Kinking of the drain
Pa
in
A.
79%
© 2010 Universitair Ziekenhuis Gent
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Chest drain management
Connection to a drainage system that contains a valve
mechanism to prevent air or fluid from entering the
pleural cavity.
1.
Underwater seal
2.
Heimlich Flutter valve
3.
Other recognised mechanism:
Electronic system (Thopaz)
Indwelling tunneled pleural catheters (PleurX - Aspira)
© 2010 Universitair Ziekenhuis Gent
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Chest drain management
Connection to a drainage system that contains a valve
mechanism to prevent air or fluid from entering the
pleural cavity.
1.
Underwater seal
2.
Heimlich Flutter valve
3.
Other recognised mechanism:
Electronic system
Indwelling tunneled pleural catheters
© 2010 Universitair Ziekenhuis Gent
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Under water seal – thoracic drainage
Basic Principles
1- bottle system
2- bottle system
3- bottle system
4- bottle system
© 2010 Universitair Ziekenhuis Gent
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1 – bottle system
Fluid drains spontaneously due to gravity
Air drains spontaneously when there is postive
pressure in the pleural cavity (e.g. tension
pneumothorax)
Thomas Malfait – schematische voorstelling thoraxdrain
1 – bottle system
Fluid drains spontaneously due to gravity
Air drains spontaneously when there is postive
pressure in the pleural cavity (e.g. tension
pneumothorax)
!!! When there is negative pressure in the pleural
space (normal condition / inspiration) air can flow
inwards
Thomas Malfait – schematische voorstelling thoraxdrain
1 – bottle system
Fluid drains spontaneously due to gravity
Air drains spontaneously when there is postive
pressure in the pleural cavity (e.g. tension
pneumothorax)
!!! When there is negative pressure in the pleural
space (normal condition / inspiration) air can flow
inwards
To overcome this the drain is sealed by water
• 2cm H20
2cm
• Easy to overcome by slight + intrathoracic pressure
• - pressure of inspiration cannot overcome the seal
Thomas Malfait – schematische voorstelling thoraxdrain
1 – bottle system
Inspiration :
Intrapleural negative pressure
– water is pulled up
Expiration :
Normalisation of intrapleural
pressure and lowering of
waterlevel.
Water is going up and down
with every breathing cycle
► ‘Pendelen’
►‘Tidaling’
►‘Oscillation’
2cm
Expiration
Inspiration
Excessive air intrapleural wil
escape by drain - exhaling
► ‘Air Leak’
Thomas Malfait – schematische voorstelling thoraxdrain
2-bottle system
Blood en fluid drains from pleural
cavity into drainage recipient.
Waterseal > 2cm
Air cannot be removed anymore
Thomas Malfait – schematische voorstelling thoraxdrain
2-bottle system
Blood en fluid drains from pleural
cavity into drainage recipient.
Waterseal > 2cm
Air cannot be removed anymore
An collector in between
► 2-bottle system
Thomas Malfait – schematische voorstelling thoraxdrain
3- bottle - system
2 bottle system = passive system
Extra negative pressure (= aspiration/suctie) more rapidly expansion of the
lung – better adherens lung to thoracic wall
Extra bottle attached after waterseal – this is connected to an aspiration
manometer :
- ‘suctioncontrol’
- the amount of water in this bottle regulates the suctionforce
- mostly15 to 20 cm water
►3- bottle - system
Thomas Malfait – schematische voorstelling thoraxdrain
3-flessen - systeem
15cm
2cm
Suctioncontrol
Waterseal
Thomas Malfait – schematische voorstelling thoraxdrain
Collector
3-flessen - systeem
!
Chest. 2005;127(6):2211-2221.
3- bottle - system
2 bottle system = passive system
Extra negative pressure (= aspiration/suctie) more rapidly expansion of the
lung – better adherens lung to thoracic wall
Extra bottle attached after waterseal – this is connected to an aspiration
manometer :
- ‘suctioncontrol’
- the amount of water in this bottle regulates the suctionforce
- mostly15 to 20 cm water
►3- bottle – system
Sommige systemen hebben dry-suctioncontrol – geen water meer
invoeren maar draaien aan knop die de suctie regelt – principe blijft
hetzelfde
Thomas Malfait – schematische voorstelling thoraxdrain
3-flessen - systeem
Wat gebeurt
als in dit
systeem
aspiratie /
suctie stopt?
15cm
2cm
Suctioncontrol
Waterseal
Thomas Malfait – schematische voorstelling thoraxdrain
Collector
Wat gebeurt als in 3 flessen systeem
suctie stopt ?
69%
Vocht en lucht blijven
verder draineren
B. Borrelen van waterslot
wordt heviger
C. Luchtlek neemt toe
D. Kans op
spanningspneumothorax
A.
20%
eu
.. .
oe
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sp
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m
kn
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a
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Ka
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va
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w
at
er
slo
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ve
...
tb
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Vo
c
© 2010 Universitair Ziekenhuis Gent
8%
3%
66
3- bottle - system
15cm
2cm
Suctioncontrol
Waterslot
Thomas Malfait – schematische voorstelling thoraxdrain
Collector
4-flessen - systeem
3-flessen systeem is een volledig afgesloten systeem
De lucht kan enkel via het afzuigsysteem ontsnappen
Indien probleem met afzuigsysteem gevaar voor pneumothorax
Hiertoe nog een 4de fles aankoppelen (vlak naast de opvangfles waar overtollige
druk toch nog een uitweg vindt
Een extra veiligheidswaterslot
Reeds vaak vervangen door balletje – vlotter langswaar lucht kan ontsnappen
Thomas Malfait – schematische voorstelling thoraxdrain
4-flessen - systeem
Suctioncontrol
Waterslot
Collector
Thomas Malfait – schematische voorstelling thoraxdrain
Veiligheidsslot
/ manometer
Chest drain management
Drain should be checked daily for
Drainage volumes – Swinging - Bubbling
Underwater seal
Beneath insertion site - Keep upright
A bubbling drain should never be clamped
A maximum of 1.5 L should be drained in the first hour
After an hour of waiting the rest can be drained off slowly
Suction :
No evidence to recommend or discourage the use of suction in
a medical scenario
© 2010 Universitair Ziekenhuis Gent
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Eens drain geplaatst
© 2010 Universitair Ziekenhuis Gent
e.
..
ro
n
dl
o
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ta
p
ag
m
Pa
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a.
.
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ag
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ro
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op
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te
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. ..
als
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zo
m
Pa
t ie
Pa
t ië
nt
D.
3%
0%
Pa
t ië
C.
oe
t
B.
Patiënt moet zo stil als
mogelijk in bed liggen
Patiënt mag opzitten
maar niet stappen
Patient mag
rondstappen maar
drainage kit lager als
insteekplaats
Patient mag rondlopen
en zwieren en zwaaien
met drainagebak
m
A.
97%
71
Chest drain management
Removal
Non functioning drain
< 200ml / 24 fluid production
Brisk movement with assistent closing the mattress
suture of holding skin firmly together
Valsalva? No evidence for difference in pneumothoraces
In case of chest drain for pneumothoraces
Clamping can be done – cave tension pneumothorax
© 2010 Universitair Ziekenhuis Gent
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Verschillende systemen van dichtbij bekeken
Atrium / Océan
Pleurevac
Flutter Valve / Heimlich
Electronisch drainagesysteem
Getunnelde permanente systemen
© 2010 Universitair Ziekenhuis Gent
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Welk systeem meest gebruikt
Atrium / Océan
B. Pleurevac
C. Flutter Valve / Heimlich
D. Electronisch
drainagesysteem
E. Getunnelde
permanente systemen
F. Andere
60%
A.
© 2010 Universitair Ziekenhuis Gent
23%
15%
0%
At
r iu
m
An
de
re
0%
/O
cé
Flu
an
tte
Pl
eu
rV
El
re
al
ec
va
ve
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c
/H
ni
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im
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tu
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nn
ai
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el
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ag
de
es
pe
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rm
.
an
en
te
. ..
1%
74
Veiligheidswaterslot
Suctioncontrol Waterslot
Collector
Dry suction
control
Verschillende systemen van dichtbij bekeken
Heimlich Valve
Unidirectionele klep
Mebraan die open en dicht kan klappen
© 2010 Universitair Ziekenhuis Gent
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Verschillende systemen van dichtbij bekeken
Electronische drainage systemen
Thopaz (©Medela)– drainage
© 2010 Universitair Ziekenhuis Gent
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©Medela
© 2010 Universitair Ziekenhuis Gent
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Filosofie
©Medela
© 2010 Universitair Ziekenhuis Gent
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Productbeschrijving
©Medela
© 2010 Universitair Ziekenhuis Gent
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Product
©Medela
Het hart van het thoraxdrainagesysteem
•
•
•
•
•
Geïntegreerde vacuümbron
Oplaadbare lithium-ionen accu
Compact design
Lichtgewicht
Geluidsarm
Technische gegevens
•
•
•
•
•
© 2010 Universitair Ziekenhuis Gent
Laag vacuüm: -100 cm H2O
Lage flow: 5 L/min
Gewicht: 1 kg
Veiligheidsklasse: IP33
Looptijd accu: min. 4 uur
85
Product
Display
© 2010 Universitair Ziekenhuis Gent
©Medela
86
86
Product
©Medela
Overloopbeveiliging
/bacteriefilter
Overdrukventiel
Veiligheidskamer
Afdichtkapjes
Opvangkamer
Gradatie
Opvangpot 0.8L
© 2010 Universitair Ziekenhuis Gent
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Product
©Medela
Slangenset
Materiaal: PVC (van medische kwaliteit)
Lengte: 1.5 m / ø 5 mm
Klem
Afvoerslang
Meetslang
Connectie naar
pomp
Slangenset enkel
Connectie naar
opvangpot
Enkele patiëntverbinding
Overloopbeveiliging
© 2010 Universitair Ziekenhuis Gent
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Functies
Iedere 5 minuten wordt er een kleine hoeveelheid lucht door beide slangen
geblazen
©Medela
closed
open
© 2010 Universitair Ziekenhuis Gent
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Functies
De druk wordt dicht bij de patiënt gemeten en wordt constant gehouden.
© 2010 Universitair Ziekenhuis Gent
©Medela
90
Functie
Een terugslagklep zorgt voor de waterslotfunctie
©Medela
open
dicht
© 2010 Universitair Ziekenhuis Gent
91
Thopaz thoraxdrainagesysteem = in essentie een 3-flessen systeem
Waterslot
Collector
Suction
control
Verschillende systemen van dichtbij bekeken
Getunnelde ‘permanente’ drainagesystemen
PleurX® catheter
(Cardinal Health, McGaw Park, IL)
Aspira® catheter
(Bard Access Systems, Salt Lake City, UT)
© 2010 Universitair Ziekenhuis Gent
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PleurX® catheter
© 2010 Universitair Ziekenhuis Gent
Aspira® catheter
94
?
© 2010 Universitair Ziekenhuis Gent
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FAQ
Welke diameter van thoraxdrain te gebruiken?
Kunnen alle thoraxdrains worden afgeklemd?
Wanneer worden thoraxdrains afgeklemd?
Mag een patiënt met een thoraxdrain bewegen?
Welke suctie wordt nagestreefd?
Hoe lang moet een drain ter plaatse blijven?
Bestaan er alternatieven voor thoraxdrain?
© 2010 Universitair Ziekenhuis Gent
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