Tube it or lose it
Just a little pokey poke
The Lung and the Restless: Pleural Drama
Deflation Nation
Important Knowledge
100
Anatomical landmarks for chest tube placement
- Inframammary fold/nipple line
- Pec major
- Latissimus dorsi
100
Most common complication of thoracentesis
Pneumothorax
100
How much fluid does the pleural space normally contain?
2-10 mL of fluid
- Fluid production capacity is 100 mL/hr. Fluid absorption capacity is 300 mL/hr.
- Fluid flux is normally from parietal pleura capillaries to pleural space with absorption by the parietal pleura
- Balance of forces favors fluid reabsorption, mostly through lymphatics of the parietal pleura
100
What are 3 clinical signs of tension pneumothorax?
- worsening dyspnea
- hypotension
- diminished breath sounds on the affected side
- distended neck veins
- tracheal deviation away from the affected side
100
How much does a Costco hotdog cost?
$1.50
200
What size chest tube do we use for an adult with a hemothorax?
32F to 36F chest tube
200
Name AT LEAST 5 tests you can order for pleural fluid analysis
cell count, protein, lactate dehydrogenase, pH, glucose, amylase, Gram stain, acid-fast and bacterial culture, and cytology
200
Light's criteria for exudative effusions
- Pleural/serum protein ratio >0.5
- Pleural/serum lactate dehydrogenase ratio >0.6
- Pleural lactate dehydrogenase >2/3 of normal serum LDH
200
What are the 3 subtypes of traumatic pneumothorax?
- Tension pneumothorax. Disruption of the visceral pleura, parietal pleura, or tracheobronchial tree occurs such that a tissue flap creates a one-way valve, permission gas to flow into, but not out of, the pleural space. The progressive intrapleural pressure increase can lead to mediastinal shift and cardiac compromise.
- Penetrating/open pneumothorax. This involves direct communication between the atmosphere and the pleural space, resulting in external air entering the pleural cavity.
- Blunt/closed pneumothorax. Sudden blunt trauma causing alveolar rupture or laceration of parenchyma by associated rib fracture creates a communication between lung and the pleural space.
200
Name all the states that border West Virginia
Pennsylvania, Ohio, Kentucky, Virginia, and Maryland
300
Name 4 indications for a chest tube
- Pneumothorax
- Hemothorax
- Pleural effusion
- Pleurodesis
300
Name AT LEAST 3 risk factors for complications of thoracentesis
- small effusions (< 250 mL)
- obesity
- loculated effusions
- supine positioning
- coagulopathy
- mechanical ventilation
- intrapleural adhesions
300
Name 2 common causative agents of empyema
- Streptococcus milleri
- Streptococcus pneumonia
- Staphylococcus aureus
- Enterobacter
- Gram-negative organisms
- Anaerobes
300
Indications for pleurodesis with relation to pneumothorax
Persistent air leak (≥ 4 days)
Failure of the lung to fully expand with adequate chest tube placement
Prevention of recurrent pneumothorax
300
What is a group of flamingos called?
Flamboyance
400
Name AT LEAST 3 Indications for urgent thoracotomy after chest tube insertion
- Blood drainage of more than 1500 mL initially or more than 300 mL/h for three consecutive hours.
- Signs of ongoing surgical bleeding
- Massive air leak with associated pneumothorax
- Drainage of esophageal or gastric contents from the chest tube
400
How do you position a patient for thoracentesis?
Position the patient sitting upright, resting his or her arms on a bedside table
If the patient is unable to sit up, they may be positioned supine or semisupine with the ipsilateral arm adducted across the chest toward the opposite side, or in the full lateral decubitus position with the hemithorax contralateral to the effusion in the dependent position
400
Name AT LEAST 3 physiological factors that contribute to the development of pleural effusions
- Increased hydrostatic pressure
- Increased negative intrapleural pressure
- Increased capillary permeability
- Decreased plasma oncotic pressure
- Decreased or interrupted lymphatic drainage
400
What is a catamenial pneumothorax?
- Caused by cyclic involution of thoracic ectopic endometrial tissue implants in conjunction with the menstrual cycle
- Most common extrapelvic location: thoracic endometriosis
400
What is the best selling Barbie of all time?
Totally Hair Barbie
Released in 1992, more than 10 million sold
Extra-long hair and came with a tube of Dep styling gel
500
Describe the steps of placing a chest tube
- Position patient supine with arm raised above head
- Sterilize, Drape
- Local anesthetic
- Skin incision at the level of the nipple/inframammary fold (4th-5th ICS)
- Divide subcutaneous and muscular tissue with blunt/sharp dissection to the rib
- Enter pleural space at the ICS of the incision or one ICS above
- Palpate to evaluate for adhesions
- Clamp tube at insertion end and insert through tract, directed at the apex posteriorly
- Advance making sure last drainage hole is within the chest cavity
- Anchor to skin with suture, place occlusive dressing
- Connect water seal/suction
- CXR
500
When should should you stop removing fluid during a thoracentesis (name 1 of the 3 general guidelines)?
There is no definitive way to ascertain the safe total volume to remove during therapeutic thoracentesis.
A general guideline is to stop fluid removal when chest discomfort ensues, the patient starts coughing, or when the total amount of fluid removed reaches 1000 to 1500 mL
500
6 significant anatomical structures to identify and preserve during VATS procedure (apical, medial, posterior, inferior)
- Subclavian artery apically
- Phrenic nerve and pericardium medially
- Aorta and esophagus posteriorly
- Diaphragm inferiorly
500
How do perform a surgical pleurodesis and what rib levels do you include? (you’ve already entered the chest)
Use a combination of Bovie electrocautery and abrasion (often achieved with a ring clamp holding a Bovie scratch pad) to roughen the parietal pleura from the fourth to fifth intercostal space apically
500
Bangui is the capital of which central African republic?
Central African Republic