please memorize and summarize the Youtube video about chest tube into subjects and explanations... 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 thesecomplex critical care subjects easy to understand i truly hope that i'm able to do just that and if i am i do invite you to subscribe to the channel down below when you do make sure you hit that bell icon and select all notifications so you never miss out when i release a new lesson as always the notes for this lesson as well as all the previous videos are available exclusively to the youtube and patreon members you can find links to join both of those down in the lesson description below also don't forget to head over to icuadvantage.com or follow that link down in the lesson description to take a quiz on this lesson test your knowledge while also being entered into a weekly gift card as well as don't forget that you can help support this channel through the purchase of an icu advantage sticker again those are found at the website icuadvanage.com forward slash support 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 indepth 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-pulmonarypressure 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 nowif 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 cancome 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 thelung 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 andhaving 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 apositive 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 ofzero 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 traumasituations 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 acouple 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 solet'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 wewant 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 toensure 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 kindof 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 thiswater 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 anyair 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 thusincreasing 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 thewhole 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 mayneed 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'regoing 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 tubeis 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 anypressure 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 soagain 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 andthese 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 leave me a like on the video down below it really helps youtube know to show this video to other people out there as well as leave me a 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