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that is done to drain fluid, blood, or air from the space around the lungs. This procedure may be done when a patient has a disease, such as pneumonia or cancer, that causes extra fluid or blood to build up in the space around the lungs (called a pleural effusion). A chest tube may also be needed when a patient has had a severe injury to the chest wall that causes bleeding around the lungs. Sometimes, a patient’s lung can be accidentally punctured, allowing air to gather outside the lung, causing its collapse (called a pneumothorax). Chest tube thoracostomy involves placing a hollow plastic tube between the ribs and into the chest to drain fluid or air from around the lungs. The tube is often hooked up to a suction machine to help with drainage. The tube remains in the chest until all or most of the air or fluid has drained out, usually a few days. Occasionally special medicines are given through a chest tube. Why Do I Need a Chest Tube? Common reasons why a chest tube is needed include: ■ Collapsed lung (pneumothorax)—This occurs when air has built up in the area around the lungs (the pleural space) from a leak in the lung. This leak may be the result of lung disease. It can also occur as a complication of certain medical procedures. Chest tubes are frequently needed to remove air from around the lung. Failure to remove such air can be life-threatening. Removing the air allows the lung to re-expand and seal the leak. ■ Infection—If the fluid building up around the lung is infected, it may be necessary to insert a chest tube to remove the fluid. Getting the fluid out sometimes helps clear the infection faster. A culture can also be done on the fluid to try to figure out what type of infection is present. ■ Cancer—Some cancers spread to the lung or pleura (lining of the lung). This can cause large amounts of fluid to build up around the lung. Doctors usually drain the fluid with a needle. If the fluid keeps coming back, however, it may be necessary to insert a chest tube to first drain thefluid, and then deliver special medicines into the chest that reduce the likelihood of the fluid building up again. ■ Comfort—A large buildup of fluid or air in the chest can make it difficult to breathe. Removing some of the fluid or air may decrease discomfort and make it easier for the patient to breathe. ■ Chest Surgery—Sometimes a chest tube is left in place after surgery. The surgeon can usually tell you if it will be needed and how long it may need to stay in. Risks of Chest Tube Insertion: Below are listed some risks of chest tube thoracostomy. It should be noted that the risk of serious
from 3⁄4 inch to 11⁄2 inches long. Sometimes a person. A sterile dressing bandage is placed over the insertion site. the procedure is likely to be done by a surgeon or a pulmonary/critical care physician. If the X-ray shows a need for a chest tube to drain fluid or air. ■ Infection—Bacteria can enter around the tube and cause an infection around the lung. is given a small amount of medicine (a sedative) that causes sleepiness before a chest tube is inserted. the greater the risk for infection. Doctors try to lessen any pain or discomfort by giving a local numbing medicine. The risk of infection is decreased by special care in bandaging the skin at the point where the tube goes into the chest. and any breathing problems you may be having. Preparation for chest tube insertion Fluid or air in the chest that needs to be drained is identified using a chest radiograph (X-ray). Sometimes pain around the area where the tube enters the chest may cause you to take more shallow breaths. The nurse or doctor will tell you how much you can move around with the chest tube in place. It will be stitched into place to prevent it from slipping out. between the ribs (the exact location depends on what is being drained and its location in the lungs). The longer the chest tube stays in the chest. you will be able to breathe more comfortably with the tube in place. The discomfort usually decreases once the tube is in place. ■ Pain during placement—Discomfort often occurs as the chest tube is inserted. Then the doctor will guide the tube into the chest. although there are different sizes that can be used. This numbing medicine will also be injected deeper in the tissue along the path through the ribs that the tube will follow. Rarely. ■ Bleeding—During insertion of the tube. Usually. What happens when the chest tube is in? You will need to stay in the hospital the entire time the chest tube is in. except when it in placed in the operating room during an open chest procedure. Bleeding is usually minor and stops on its own. The skin will be thoroughly cleaned and a local anesthetic medication will be injected into the skin. Your doctor will explain the risks and how likely they may be for you when you give consent for the procedure. You will be checked often for possible air leaks. a blood vessel in the skin or chest wall may be accidentally nicked. The tube is usually a little thinner than a pinky finger. The doctor will use a scalpel to make a cut. Sometimes other tests. Sometimes the tube . bleeding can occur into or around the lung and may require surgery. Often an adult or older child remains awake when a chest tube is inserted.complications (bleeding and infection) is uncommon (usually less than 5% of cases). plugging of the tube. particularly a younger child. such as a chest ultrasound or chest CT are also done to evaluate pleural fluid. Usually bleeding can just be watched with the chest tube in place.
there may be bronchial breathing and egophony. Usually it can be taken out right at your bedside. Above the effusion. such as decreased movement of the chest on the affected side.7. and confirmed by chest x-ray. There rarely is a need for sedation medication. a follow-up chest X-ray will be done to make sure that fluid or air haven’t come back. In large effusion there may be tracheal deviation away from the effusion. cannot be seen. Types of fluids Four types of fluids can accumulate in the pleural space: Serous fluid (hydrothorax) Blood (haemothorax) Chyle (chylothorax) Pus (pyothorax or empyema) Diagnosis Pleural effusion is usually diagnosed on the basis of medical history and physical exam.8). where the lung is compressed. Excessive amounts of such fluid can impair breathing by limiting the expansion of the lungs during ventilation.is clamped and left in place to make sure no fluid or air comes back before it is pulled out. diminished breath sounds on the affected side. 0. the visceral pleura and the parietal pleura. 95% confidence interval.12–0. Often. 8. Imaging A pleural effusion will show up as an area of whiteness on a standard posteroanterior X-ray. 95% confidence interval.37).  Normally the space between the two layers of the lung. and pleural friction rub. the fluid-filled space that surrounds the lungs. . stony dullness to percussion over the fluid. You will only have a small scar. Generally there are no complications from the chest tube once it has been removed. 0. You will be told how to breathe as the tube is being pulled. Pathophysiology Pleural fluid is secreted by the parietal layer of the pleura and reabsorbed by the visceral layer of the pleura. there are usually detectable clinical signs in the patient. while the absence of reduced tactile vocal fremitus made pleural effusion less likely (negative likelihood ratio. You will be told when the bandage can be removed. A systematic review (2009) published as part of the Rational Clinical Examination Series in the Journal of the American Medical Association (JAMA) showed that dullness to conventional percussion was most accurate for diagnosing pleural effusion (summary positive likelihood ratio. Once accumulated fluid is more than 300 ml. it will be removed.2–33. A secure bandage will be put in place. Pleural effusion is excess fluid that accumulates between the two pleural layers. decreased vocal resonance and fremitus (though this is an inconsistent and unreliable sign). Will there be any pain or possible complications when the chest tube is removed? When the doctor determines that you no longer need the chest tube.21. 2.
albumin. Chemical composition including protein. conforming to the shape of the lung and chest cavity. Inflammation Decreased colloid osmotic pressure Clear Cloudy Appearance . Cytopathology to identify cancer cells. it can be seen on radiographs. but may also identify some infective organisms 5. or eighth intercostal space on the midaxillary line. The fluid may then be evaluated for the following: 1. Chest radiographs acquired in the lateral decubitus position (with the patient lying on his side) are more sensitive and can pick up as little as 50 ml of fluid. A needle is inserted through the back of the chest wall in the sixth. blunted costophrenic angles). Cell count and differential 4. then the fluid will have a "fluid level" that is horizontal instead of conforming to the lung space. viral culture. it will gravitate towards the lower portions of the pleural cavity. Because the pleural effusion has a density similar to body fluid or water. lactate dehydrogenase (LDH). into the pleural space. seventh. exudate: Light's criteria Transudate vs. amylase. At least 300 ml of fluid must be present before upright chest films can pick up signs of pleural effusion (e. specific immunoglobulins Transudate vs.A pleural effusion infiltrates the space between these layers. Gram stain and culture to identify possible bacterial infections 3. If the pleural cavity contains both air and fluid. pH. and glucose 2. fungal culture. Since the effusion has greater density than the rest of the lung. Other tests as suggested by the clinical situation – lipids. Pleural fluid is drawn out of the pleural space in a process called thoracentesis. Thoracentesis Once a pleural effusion is diagnosed.g. the cause must be determined.. exudate view talk edit Transudate Exudate Main causes Increased hydrostatic pressure. The pleural effusion behaves according to basic fluid dynamics.
5 > 0.012 < 25 g/L > 1.5 > 1.2 g/dL < 1.2 g/dL fluid LDH < 0.6 or > ⅔ > 45 mg/dL Instruments for needle biopsy of the pleura .Specific gravity Protein content fluid protein serum protein Difference of albumin content with blood albumin < 1.6 or < ⅔ upper limit for serum Cholesterol content < 45 mg/dL See also: Rivalta test > 0.020 > 35 g/L < 0.
. Exudative pleural effusions. left ventricular failure. a pleural effusion is likely exudative if at least one of the following exists: 1. cancer. renal failure. The components of the Starling forces–hydrostatic pressure. Pleural fluid LDH is greater than 0. twenty-five percent of patients with transudative pleural effusions are . e. pulmonary embolism. using Light's criteria. An accurate diagnosis of the cause of the effusion. but examples include 200 and 300 IU/l. and cirrhosis.6 3.6  or ⅔ times the normal upper limit for serum. transudate is produced through pressure filtration without capillary injury while exudate is "inflammatory fluid" leaking between cells.g.g. bacterial pneumonia. Although Light's criteria are relatively accurate.5 2. 1972). oncotic pressure (effective pressure due to the composition of the pleural fluid and blood)– are altered in many diseases. permeability. are caused by alterations in local factors that influence the formation and absorption of pleural fluid (e. relies on a comparison of the chemistries in the pleural fluid to those in the blood. Different laboratories have different values for the upper limit of serum LDH. Transudative pleural effusions are defined as effusions that are caused by systemic factors that alter the pleural equilibrium. transudate versus exudate. by contrast.Definitions of the terms "transudate" and "exudate" are the source of much confusion.. The ratio of pleural fluid protein to serum protein is greater than 0. The ratio of pleural fluid LDH and serum LDH is greater than 0. or Starling forces. hepatic failure. and viral infection). et al. Briefly. According to Light's criteria (Light.
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