Chest Tubes 4/6/04

1- What are chest tubes used for?

2- Where exactly is a chest placed?
3- How does the three-chamber system work?
4- Can suction be bad for the patient?
- What is the difference between exudate and transudate! and why do we care?
"- What is an effusion?
#- How are effusions treated?
$- When should a chest tube for effusions be remo%ed?
&- What is pleurodesis?
1'- How are mali(nant effusions treated?
11- What is streptokinase used for when it is (i%en throu(h a chest tube?
12- What is empyema?
13- What exactly is an air leak?
14- How can you tell if the chest tube port is out of the chest?
1- How can this be fixed?
1"- )re air leaks (ood or bad?
1#- Would that be a bad situation?
1$- What is the black button on top of the pleure%ac for?
1&- What is tube *strippin(+?
2'- How could , tell if a patient were de%elopin( a tension situation in her chest?
21- What is a pulsus paradoxus?
22- -hould you e%er clamp a chest tube?
23- What if the chest tube (ets pulled out by mistake?
24- What is *water seal+?
2- What is subcutaneous emphysema! and what does it ha%e to do with chest tubes?
.lease keep the followin( in mind as you read this /)01 the information written here is meant to
reflect the knowled(e and experience (ained o%er *too many+ years of ,C2 nursin( at the
*trenches+ le%el3 4y idea is to pro%ide useful information for the newer nurse at the bedside! the
kind of information that a preceptor would pass on to a newer staff member in orientation on the
unit3 ,t is not meant to be any kind of *official+ reference! and it is certainly not meant to be the
final word on any 5uestion of any kind6 7he (oal is comprehension3 ,f you see an error! or think
somethin( isn8t clear! let me know! and we8ll chan(e it ri(ht away3 , think that these files will be
much more useful if e%erybody (ets to contribute3 7hanks6
Copyri(ht materials used with permission of the
author and the 2ni%ersity of ,owa9s :irtual Hospital1 www3%h3or(3
7hanks ,owa6 ;*,s this hea%en?+! *<o! it8s :irtual ,owa=+>3
1
1- What are chest tubes used for?
Chest tubes are lon(! semi-stiff! clear plastic tubes that are inserted into the chest! so that they
can drain collections of fluids or air from the space between the pleura3 ,f the lun( has been
compressed because of this collection! the lun( can then re-expand3
-ome reasons for insertin( a chest tube1
Pneumothorax1 a collection of air in
the pleural space3 7hese can happen
spontaneously1 , saw a youn( man
walk into the ?@ once! who *Aust didn8t
feel ri(ht+ - he had a nearly completely
collapsed ri(ht lun(3 .neumos can
occur after central line insertion! after
chest sur(ery! after trauma to the
chest! or after a traumatic airway
intubation3 ,mportant to remember1 if
the air continues to collect in the
chest! the pressure in that collection
can rise! and push the whole
mediastinum o%er to the other side -
this is called a *tension
pneumothorax+! and is definitely life-threatenin(3 Call the sur(eon3
http1BBwww3henryfordhealth3or(B1$"23cfm
Hemothorax1 a collection of blood in the pleural space!
maybe from sur(ery! maybe from a traumatic inAury3
7his is actually a hemo-pneumo-thorax1 blood and air=
http1BBwww3henryfordhealth3or(B1$143cfm
2
Here8s a really nice picture from the 2ni%ersity of ,owa8s :irtual Hospital! used with permission3
-ee the shifted mediastinum? C the trachea8s sho%ed o%er to the ri(ht3
.us can collect in the pleural space - *empyema+3
/luid! usually serous! maybe from CH/! sometimes from a tumor process! will collect
between the pleura - *pleural effuson+3

)nother nice picture from ,owa C bi( effusion there
on the ri(ht6 ;<o! @alph C the patient8s ri(ht6>
3
!- Where exactly s a chest tube placed?
7he chest tube is inserted by a sur(eon! usually thoracic! but sometimes someone from the
(eneral sur(ical ser%ice3 7he entry point is the fourth or fifth intercostal space! on the mid-axillary
line! which is pretty close to the point at which you le%el a line transducer3 7he tube is inserted
towards the collection1 sometimes up and in front! or up and in back! or where%er the collection
lies3
"- Ho# does the three-chamber system #or$?
We use a de%ice called a pleure%ac! a lar(e plastic
box with what seems like fourteen separate
compartments in it - actually the ideas behind it are
not hard to (rasp3 7he box actually imitates an old
system that was in%ented to drain chest tubes! which
used three chambers - they were actually (lass
bottles held by a metal rack - in series3 ;, remember
those (lass setups - , must be (ettin( really old3>
http1BBwww3proasepsis3comBproductos3html
http1BBhome3ewha3ac3krBDchests(Bdon(BposterB&&B2-'$3Ap(
Wow C look what you can find if you hunt around on the web=the patient8s lookin( %ery relaxed6
*Chest tube placement in tannin( booth=+
-o C first! take a look at the sin(le-bottle setup there on the left of the picture33 what , was tau(ht
to call an *air trap*! or *air leak chamber+3 7he idea here is pretty simple1 suppose you had a chest
tube freshly inserted into your patient! with the end han(in( loose3 7he patient could suck air
4
directly into her chest throu(h the tube if that
distal end wasn8t controlled somehow -
maybe with a one-way flapper on the end?
-o that the air the patient pushed out of her
chest would (o out! but none would (et
sucked back in?
How about puttin( the distal end of the tube
into a cup of water? Er a bottle of water?
7hat would work as a one-way %al%e! unless
the patient were able to breathe in hard
enou(h to suck up the water - how about
puttin( the bottle of water at the end of a
lon( tube! far away from the patient - so she
couldn8t suck the water back? 7hat8s how
the air trap works3 7he trap is filled with
water at some distance from the patient -
look at how lon( the draina(e tube is on a
pleure%ac sometime - and only lets air out!
not back in3 Fubbles mo%in( throu(h the
trap means that the patient has an *air leak+!
and that the tube is drainin( air properly
;that8s what it8s supposed to mean - more on
troubleshootin( below3>
7his isn8t 5uite the one we use! but it8s close enou(h to
point arrows at1
)ir comin( out of the patient will bubble out here! which
is the defninition of an *ar lea$+3 <o bubbles! no leak3
/irst bottle3
Here8s where the draina(e comes out3 -econd bottle3
Here8s where the water column (oes3 7hird bottle3
http1BBwww3auh3dkBakhBafdBafd-nBintensi%BprocedurerBbila(Bbil113htm
-o a sin(le-chamber setup would work if the only thin( comn( out of the patient8s chest was air C
what if there8s fluid in there that needs drainin(! too? 7ime for a second bottle3
,n the multi-bottle setups abo%e! the second chamber is the air trap! while the first collects fluid
drained from the patient1 blood! or serous fluid from the pleural space3 Gou may be surprised at
how rapidly these can fill up in certain situations - for example! tumor-related effusions can drain
more that a liter - or two liters C in a day3 Gou8ll ha%e to chan(e the pleure%ac when it8s full3 Ths s
the only tme that #e routnely clamp a chest tube - remo%e the clamp after the boxes are
switched3 Hon8t for(et6
Hey C here8s an idea1 what about addin( suction to this arran(ement? ,t only makes sense that it
would help drain the patient8s chest if you could (ently suck air and fluid out of her pleural space!
ri(ht? Fut if you hook up suction from the wall! e%en with a re(ulator! you mi(ht pull too hard=
now you need the thrd bottle3 7o deli%er %ery precise suction! we use the wei(ht of a measured
column of water! which shouldn8t chan(e as lon( is it8s topped up now and then3
7he re(ulated wall suction is applied to a partly-water-filled plastic column in the pleure%ac box!
abo%e the water le%el - and the wei(ht of the water acts as a suction limiter3 <o matter how hard
the wall suction pulls! the actual suction deli%ered to the patient is only as hard as the amount
5
re5uired to pull air out past that fixed wei(ht of water3 )ny suction abo%e that Aust pulls in air from
outside the box! throu(h a %ent3 7he incomin( air bubbles throu(h the column! which is what
makes all the noise you hear when the box is hooked up to the wall suction3 )ll you need to apply
is enou(h to make it bubble C more than that Aust makes noise! and makes the water e%aporate3
Eh yes1 fill a pleue%ac up with sterile water instead of normal saline3 )s saline e%aporates! it will
actually ;a sur(eon told me once>! lea%e salt crud on the sides of the box chambers=
4- Can sucton be bad for the patent?
Eb%iously! you need to control the amount of suction applied to the patient3 4ake sure you ha%e
your pleure%ac set up correctly3 7he sur(eon who inserts the tube should order a specific water
le%el in the control column - we usually fill it to 2' cm! but sometimes they order less3
%- What s the dfference bet#een transudate and exudate& and #hy do #e care?
*7ransudates+ and *exudates+ are descripti%e names for types of fluids that can collect in the
pleural space3 7ransudates you mi(ht think of as *thinner+ - they often result from CH/! and you
mi(ht think of them as more *watery+! bein( *sweated+ into the pleural space when a patient is
*wet+3 ?xudates mi(ht be thou(ht of as *thicker+ - they contain more protein! and usually result
from some kind of inflammatory process3 7hey can also be a result of tumor processes - patients
with lun( Ca or pleural mets often show up with exudati%e fluid collections3 Gou tell the difference
by sendin( thoracentesis specs to the lab3
6- What s an effuson?
7ransudates and exudates are types of effusions - the idea bein( that the collections of fluid are
*sweated+ from the lun(3 @ecurrent effusions can be a real problem for a patient who is dealin(
with a lon(-term illness! but as lon( as the patient has a reasonable hope for li%in( a while yet!
there is (ood reason to treat the effusion! either with treatment for underlyin( CH/! or for an
underlyin( tumor process! or for whate%er else is causin( the problem3
'- Ho# are effusons treated?
,n the short term! with a chest-tube3 -ome effusions related to CH/ can be treated with diuresis -
the idea is that decreasin( the amount of the water component in the blood will cause the effusion
to be re-absorbed3 ,f the effusion is lar(e enou(h to produce respiratory distress! or tension
symptoms! you ob%iously would think more about insertin( a chest tube3
(- When should a chest tube for effusons be remo)ed?
*When it8s safe to to do so3+ 7his sounds stupid until you stop and think about the underlyin(
reason why the tube was inserted in the first place3 ,s the effusion Aust (oin( to re-collect after the
ori(inal one is drained? 4aybe somethin( needs to be done to stop the effusion from recurrin(!
like *pleurodesis+3
*- What s pleurodess?
.leurodesis is a techni5ue of instillin( some substance or other into the pleural space throu(h the
chest tube! which is then supposed to *weld+ the pleura to(ether by scarrin( them! pre%entin( the
re-collection of fluid between them3 7his doesn8t sound like it would be a %ery pleasant idea! but it
6
works pretty well for some situations3 , remember the old days! when the scarrin( a(ents used to
cause a lot of pain - ,8m sure that they weren8t chosen to be painful! but they were - let8s for(et
about those= <owadays they use sterile talcum powder! which comes up from the pharmacy in
lar(e sterile syrin(es and looks stran(e - apparently it works %ery well3
10- Ho# are mal+nant effusons treated?
7alcum powder is instilled into the pleural space! ri(ht throu(h the chest tube3 7hen the patient
(ets rolled around into different positions e%ery whichy-way so that the scarifyin( a(ent (ets
distributed e%erywhere3
11- What s strepto$nase used for #hen t s +)en throu+h a chest tube?
-ometimes you8ll see narrow-(au(e chest tubes inserted instead of the lar(e clear ones! and
because they8re narrow! they (et can plu((ed up with fibrin! which stops the draina(e3 7he tube
in this case is usually ri((ed with a stopcock between the end of the tube and the connector to
the pleure%ac - the team will instill a dose of streptokinase throu(h the stopcock and into the
patient throu(h the chest tube! let it sit for half an hour! and then turn the stopcock back to drain3
7he dose , see (i%en is 2'!''' units3
-trepto is also inAected if the patient has a *loculated+ effusion! which means that it8s mana(ed to
become surrounded by a fibrin membrane3 7he dru( breaks up the membrane and lets the
effusion (et to the tube for draina(e3
1!- What s empyema?
7his is a collection of pus in the pleural space! or in a bi( abscess space in the lun( tissue itself3
/eh6 .us can collect in lar(e enou(h 5uantities to
compress the lun(! and certainly will act as a
septic *focus+ until it8s drained3 ?mpyema can
result from chest trauma - say! a (unshot or knife
wound - or necrotiIin( pneumonia! or any other
process that puts bacteria into the chest3
)nd you were wonderin( why your patient was
on pressors? )ctually! that8s a (ood 5uestion1 new
,C2 nurses! why mi(ht this situation make your
patient need pressors? Jook one para(raph up for
the hint3
http1BBwww3koreacna3or3krBcuecomBdiseasecareBrespiratoryB'#3respiration-empyema3htm
1"- What exactly s an ,ar lea$-?
7he idea of usin( chest tubes to remo%e air from the pleural ca%ity means that there has to be
some way to tell that air is actually comin( out3 7he smaller bubble chamber in the pleure%ac
shows an air leak %ery simply - if there are bubbles comin( throu(h it! then air is comin( down the
7
tube and bein( e%acuated3 ,t8s important to remember that this does not mean automatically that
air is comin( out of the chest3 ,f there8s a leak in the tubin(! or if a chest tube suction port ;the
openin(s alon( the lumen of the tube inside the chest that draw in the air and fluid for draina(e> is
outside of the chest wall! then air will be sucked in there - instead of bein( pulled out of the chest3
-o bubbles are a (ood si(n! but you ha%e to check e%erythin( else too3
14- Ho# can you tell f the chest tube port s out of the chest?
-ometimes you8ll suddenly hear a new sound in your room3 Huntin( around! you may find that
your patient8s chest tube has inad%ertently taken a yank - and it8s whistlin( at the insertion site3 )
port has come outside the skin! and it8s continuously suckin( in air from the atmosphere around it3
Gou can put your stethoscope on the dressin( o%er the site if you8re suspicious! and you8ll hear it
clearly there3
7ake a look at this picture C one of these chest tubes isn8t 5uite ri(ht3 -ee the radio-opa5ue lines
(oin( alon( the tubes? Jook at the one on the patient8s left3 -ee the break in the line? 7hat8s the
draina(e openin(3 <icely inside the chest? -o what about the one on the other side?
1%- Ho# can ths be fxed?
,f you take the site dressin( down! you can wrap the port with sterile %aseline (auIe and apply an
occlusi%e dressin(! but usually this situation means that the tube will need to be replaced3 Gou8ll
also need a stat x-ray - air may be dan(erously re-accumulatin( in the chest6
8
16- .re ar lea$s +ood or bad?
,t depends on the situation3 ;?%erythin( always depends on the situation6> ,f a patient has a chest
tube put in for a pneumothorax! then at least initially an air leak is a %ery (ood thin( - because
you certainly want that air out of there3 ,f you don8t see bubbles comin( out throu(h the air leak
chamber after a tube is placed for a pneumo - then you may ha%e a non-functionin( chest tube on
your handsK it mi(ht not be in the ri(ht place3 Let a look with the team at the followup x-ray
immediately to see if the pneumo has shrunk at all - if not! the patient may need another tube put
in3 -ame thin( is true for a number of postop situations in%ol%in( chest sur(ery1 open lun(
biopsies! lobectomies! pneumonectomies - all these lea%e an area of lun( tissue that will leak air
into the pleural space until they heal! and so re5uire chest tubes to (et rid of that air3 -o air leaks
in those cases are also (ood3 Fut say a patient still had an air leak two weeks after an open lun(
biopsy - what then?
1'- Would that be a bad stuaton?
.robably - either the chest tube is leakin( and suckin( air in around itself somewhere - which
means it isn8t workin(! and ou(ht to be pulled anyhow! or it means that the patient is continuin( to
leak air into her chest - at this distance from the operation! this would mean that the tissue leakin(
the air into the pleural space isn8t healin( - and in fact the patient may ha%e de%eloped a broncho-
pleural fistula - meanin( a semi-permanent tract connectin( a bronchus and the pleural space3
7his happens a lot with patients who need a lot of inspiratory pressure from the %ent - say!
pressure control of 2cm! and peep of 1'cm! addin( up to 3cm of forward pressure! bein(
pushed into stiff! noncompliant lun(s3 7hat8s a lot3 7hat much pressure means that air is bein(
pushed pretty hard into those stiff lun(s! and that air will be pushed out into the pleural space too!
pre%entin( it from healin( closed3 7hat healin( won8t occur until that pressure can be mostly
reduced! but the patient will lose a lot of %entilation because of the loss of %olume throu(h the
fistula3 ) tou(h spot to be in3 7ime for permissi%e hypercapnia? Class C look that one up and (et
back to me=there will be no 5uiI! howe%er3 Gou are safe here in the /)06
1(- What s the blac$ button on top of the pleuro)ac for?
7his is actually pretty important3 Lo back to the picture on pa(e ! and look at item H3 -ee that
button? 7he air leak chamber of a pleure%ac! Aust like the first bottle of a draina(e set! needs to
be partly filled with water C that8s how the bubble-trap idea works! like puttin( the end of the chest
tube in a cup of water! like a one-way %al%e3 Gou put that water into that chamber when you set up
the pleure%ac! throu(h a fillin( column that has an openin( on the top of the box3
,f you remember to look at the air leak chamber at %arious times durin( the course of your shift!
you8ll notice that the water in it can sometimes rise up the fillin( column towards the top of the
box3 7his usually happens if the patient is *pullin(+ %ery hard with inspiration - what they call
*excess ne(ati%e pressure+3 Mind of like what hi(h school teachers do=in other words! not only is
the patient tryin( to pull in air throu(h his airway! but also from the pleure%ac itself! which actually
he can8t! because that8s what the air leak chamber pre%ents! ri(ht? Fut the water in the trap
chamber will rise up in the fillin( column after a while! and the air that8s tryin( to escape from the
chest won8t be able to (et out because of the increased wei(ht of that column3
7he resistance of the air trap! or leak chamber filled with water to the proper le%el! is only
supposed to be tiny - about 2cm of water - not like the 2'cm in the control column3 -o what you
ha%e to do is lower that column of water back down to the le%el indicated on the chamber - there8s
a line marked on the box3 Holdin( down the black button is the thin( to do - hold the button down!
and the column will slowly sink down towards the correct le%el - let (o when it (ets there3 7his
problem also happens %ery often with tube *strippin(+3
9
1*- What s tube ,strppn+-?
-trippin( is somethin( people ar(ue about a lot3 7he idea is that if a chest tube is *milked+ e%ery
couple of hours after! say! a sur(ical procedure! then it won8t (et plu((ed up by clots! which only
makes sense! since if the tube (ets plu((ed! then the air and fluid that it8s supposed to remo%e
will not (et remo%ed! and a tension situation could de%elop in the chest3 Hefinitely a bad thin(3
Fut strippin( and milkin( can pull too hard suction-wise on the chest ca%ity! possibly causin(
tissue inAuries to the lun(3 )lso a bad thin(3 -o the only thin( to do is to ask the sur(eon what she
wants done3 ,f you8re instructed not to strip! watch carefully for si(ns that the chest tube is still
workin( properly1 drainin( air! fluid! or blood3 ,f air were to stop comin( out three hours postop a
lobectomy - ,8d pa(e that sur(eon ri(ht away3
!0- Ho# could / tell f a patent #ere de)elopn+ a tenson stuaton n her chest?
-ometimes the si(ns and symptoms are ob%ious! sometimes not3 7he first thin( to do if you
suspect this is to (et the team to order a stat chest film - and then (et it promptly read6 Ebser%in(
the patient! you mi(ht see hypotension! cyanosis! (eneral si(ns of respiratory distress - maybe
e%en tracheal de%iation to the opposite side as the mediastinum (ets pushed across the chest3 ,f
the patient has an arterial line! look for a pulsus paradoxus3
!1- What s a pulsus paradoxus?
7he idea here is that blood pressure %aries as the patient inhales and exhales1 literally (oes up
and down! maybe by ' points! systolic3 4aybe more3 7here are three main situations where you
see this1 tension pneumothorax! pericardial tamponade! and ;maybe> se%ere hypo%olemia3
Jet8s take the first one! which is the rele%ant one here1 what happens is that as the patient (ets a
breath! the intrathoracic pressure rises3 7he tension (ets worse - maybe there8s already some
mediastinal compression3 7he heart is s5ueeIed ti(htly! and compressed! and literally doesn8t
ha%e room in the chest to pump3
7his makes sense if you think about tension pneumothorax - a lun( may (o all the way down! and
as the pressure in the chest continues to rise and rise! with e%ery breath! the mediastinum (ets
pushed o%er harder and harder3 -o now when the patient (ets a breath! the small addition of
positi%e pressure ;assumin( they8re %ented - in which case positi%e pressure happens on
inspiration because the %ent is pushin( the air in> the heart (ets s5ueeIed Aust a little more! is
able to mo%e Aust a little less - can8t pump well - and the blood pressure drops3
When the patient exhales ;on the %ent! this is when intrathoracic pressure is released - after the
breath is pushed in> - then the intrathoracic pressure drops a(ain! and the heart is un-s5ueeIed a
bit! the heart can mo%e Aust a little better! and the blood pressure rises a(ain3 7his can sometimes
be clearly seen if the patient has an arterial line - watch the tops of the blood pressure wa%es on
the )-line as the breaths (o in and out - if they drop more than 1-2' points per breath! you8%e (ot
a *clinically si(nificant+ pulsus paradoxus - often a %ery clear classic si(n of pneumothorax3 7hink
about it - did the patient Aust ha%e a central line put in=?
Gou can measure this by usin( the arterial line cursor - there is one there! althou(h we hardly
e%er use it3 Chase the wa%e tops up and down! measurin( the distance between the tops at
inspiration and the tops at expiration! and find the difference3 Gou mi(ht see a dramatic chan(e C
in a se%ere situation! maybe a systolic of 1' droppin( to $'3
10
Here8s a nice sample of a pulsus paradoxus showin( up on an arterial-line wa%eform1
http1BBcritcare3lhsc3on3caBeduNbriefsBAan#a''3html
-ee the pressures (oin( upand down? ,C2 nurses1 is this patient %ented! or not? 7ry to calculate1
is this pulsus (reater than 2' points?
!!- 0hould you e)er clamp a chest tube?
)side from chan(in( the pleure%ac! it sounds like a bad idea to me3 ,f the pleure%ac tubin( comes
disconnected from the chest tube itself! then , would clamp the tube only lon( enou(h to hook up
another one! to pre%ent air from bein( sucked back into the chest3 Fut only that lon(6 Hid the tube
(et contaminated?
!"- What f the chest tube +ets pulled out by msta$e?
7hat8s what you keep %aseline (auIe at the bedside for3 Gou would slap that (auIe ri(ht onto the
site! ;don8t really slap the patient! ri(ht?> and occlude the openin( - you don8t want air (oin(
back into the patient8s chest C for the same reason why you8d ;briefly6> clamp a chest tube in the
5uestion abo%e3 )(ain! you8d want to stat pa(e a sur(eon if the patient needed the tube back in!
and (et a CO@ ordered ri(ht away3
!4- What s ,#ater seal-?
*Water seal+ means that you8%e disconnected the wall
suction line from the pleure%ac ;on purpose>3 2sually this
is ordered when the air andBor fluid drainin( from the
patient is assumed to be pretty much o%er and done with -
se%eral days after sur(ery - maybe not in the case of
recurrent effusion - maybe a day or so after pleurodesis
when you8d expect the draina(e to ha%e stopped3 Gou8d
want to watch carefully for si(ns of re-accumulatin( air or
fluid in the chest - daily! or sometimes twice-daily x-rays
will help determine this3 ,t8s done as a maneu%er when
you8re thinkin( about pullin( the tube after it8s ser%ed its8
purpose3
11
!%- What s subcutaneous emphysema& and #hat does t ha)e to do #th chest tubes?
-ubcutaneous emphysema is the collection of air in the
tissues Aust under the skin C once you feel it! you8ll
ne%er for(et it1 as thou(h @ice Mrispies had been
spread around under the patient8s skin3 ,f a chest tube
isn8t properly placed! or maybe if the site dressin( isn8t
airti(ht! air can leak into the tissue around the insertion
site3 ?%entually it can track up and down the body!
sometimes causin( the neck and face to swell!
sometimes threatenin( the airway3 ,n that case the
patient should be immediately assessed for intubation -
there may be no time to waste6 Correctin( the position
of the chest tube usually stops the leaka(e of air into
the tissues! and the air itself is almost always %ery
rapidly reabsorbed - a matter of se%eral days at most!
in my experience3
http1BBwww3aic3cuhk3edu3hkBweb$BchestNinAuries3htm
Hard to tell which side it8s comin( from C both eyes are certainly swollen! aren8t they? ,s this
patient really a little hea%y-set! or is that air in her facial tissue? )ctually! if her eyes look like that!
it8s probably the second=
12