a personal guide to

M A N A G I N G

Dry SuctionWater Seal

Chest Drainage

Table of ContentsYour personal guide to Managing Dry Suction ChestDrainage is a quick and easy reference to help extend yourunderstanding of dry suction chest tube drainage and to helpanswer questions which may come up from time to time. It isprovided as an educational service of Atrium, the leadingproducer of water seal chest drainage systems. This booklethas been prepared as an educational aid only and is notintended to replace any medical or nursing practices orhospital policies. Due to numerous model types available, it isimportant to carefully read and follow each correspondingproduct insert prior to use.

Introduction Making It Simple To Understand . . . . . . . . . . . . . . . . . . . . . 4

How Dry Suction Water Seal CDUs FunctionThe Basic Operating System . . . . . . . . . . . . . . . . . . . . . . . . . 5Fluid Collection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6Water Seal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6Dry Suction Control . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

The Atrium SystemAll The Water You Need...And Less! . . . . . . . . . . . . . . . . . 8Features, Benefits, Function . . . . . . . . . . . . . . . . . . . . . . . . 10Product Feature Summary . . . . . . . . . . . . . . . . . . . . . . . . . 12

System Set UpOpen Package . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14Requirements For Set Up . . . . . . . . . . . . . . . . . . . . . . . . . . 14Four Step Set Up . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

What To Check During System OperationVerifying Suction Operation . . . . . . . . . . . . . . . . . . . . . . . . 18Increase Vacuum Source When BellowsIs Not Expanded To sMark . . . . . . . . . . . . . . . . . . . . . . 18

2

Changing Suction Pressures . . . . . . . . . . . . . . . . . . . . . . . . 19Recording Drainage Volume . . . . . . . . . . . . . . . . . . . . . . . 19Placement Of Unit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19Verifying Water Seal Operation . . . . . . . . . . . . . . . . . . . . . . 20Observing Changes In Patient Pressure . . . . . . . . . . . . . . . 20High Negativity Float Valve . . . . . . . . . . . . . . . . . . . . . . . . . 20Observing Water Seal For Patient Air Leaks . . . . . . . . . . . . 21Graduated Air Leak Monitor . . . . . . . . . . . . . . . . . . . . . . . . 21Sampling Patient Drainage . . . . . . . . . . . . . . . . . . . . . . . . . 21Manual High Negativity Vent . . . . . . . . . . . . . . . . . . . . . . . . 22Positive Pressure Protection . . . . . . . . . . . . . . . . . . . . . . . . 22Swing Out Floor Stand . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22Multi-Position Hanger Holders . . . . . . . . . . . . . . . . . . . . . . 22In-Line Patient Tube Connector . . . . . . . . . . . . . . . . . . . . . 23Patient Tube Clamp . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23Gravity Drainage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23System Disconnection . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

Anatomy And Physiology ReviewAnatomy Of The Chest . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24Why The Lungs Are Expanded . . . . . . . . . . . . . . . . . . . . . . 25The Mechanics Of Breathing . . . . . . . . . . . . . . . . . . . . . . . . 26

Why Water Seal CDUs Are UsedClinical Needs For Chest Tube Drainage . . . . . . . . . . . . . . . 27

What To Check For During CDU Use . . . . . . . . 30

Chest Tube PlacementChest Tube Insertion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31Chest Tube Nursing Responsibilities . . . . . . . . . . . . . . . . . 32

Troubleshooting GuideQuestions And Answers . . . . . . . . . . . . . . . . . . . . . . . . . . . 33

3

Introductionn Making It Simple To UnderstandTo restore the chest to its normal condition, all air and fluidmust be removed, and the source of an air leak must beclosed. The purpose of any chest drainage device is to helpre-establish normal vacuum pressures by removing air andfluid in a closed, one-way fashion.

The need for chest drainage is also required following openheart surgery and chest trauma to evacuate any poolingblood which, if left in the mediastinal cavity, can cause cardiacdistress or tamponade. Hence, chest drainage is indeed alife-saving procedure and one of the most important servicesa physician and nurse clinician can render.

While the practical application of water seal chest drainagetechniques are relatively simple, sometimes the chest drainand its accompanying terminology may appear complex.However, dry suction water seal chest drainage systems areactually quite simple to manage and easy to understand. It isour hope that a review of the educational aid booklet will helpenhance your working knowledge of chest drainage andfurther familiarize you with Atrium's easy-to-use dry suctionwater seal operation system.

n Customer ServiceIf a question or need arises for customer service, product infor-mation, or to request inservice educational material, we inviteyou to call or FAX Atrium's hotline anytime.

In the U.S.A. 1-800-528-7486Outside the U.S.A. 603-880-1433FAX 603-880-6718www.atriummed.com

4

How Dry Suction Water SealCDUs Functionn The Basic Operating SystemToday’s water seal drainage systems are comprised of aone-piece, 3-chamber set up, which separates the functionsof fluid collection, water seal (which serves as a simple one-way valve), and suction control. An easy way to describe theone-way action of a water seal is to refer to a cup of water and astraw. If one were to blow air into a submerged straw, air wouldbubble out through the water. Now if you wanted to draw theair back through the straw, you would only draw water. Hence,when chest drainage came into light many years ago, the one-way action of a water seal (water bottle and straw concept) pro-vided a simple but ideal means for evacuating air and not allow-ing it to return to the patient.

5

From patient

Collectionchamber

Water sealchamber

To suction

Drysuctioncontrol

Air leakmonitor

Recently, advances in engineering have enabled dry suc-tion technology to be incorporated into familiar water sealoperating systems. Consequently, today’s dry suction waterseal operating systems not only provide a simple and conve-nient method to maintain a required amount of vacuum ina patient’s chest, but now provide faster set up times, quietoperation, and the ability to impose higher levels of controlledsuction with the simple turn of the dial. Additionally, thesenew compact, lightweight chest drains better address the hos-pital’s critical need for reduced disposal costs.

n Fluid CollectionIn a dry suction water sealoperating system, fluids drainfrom the patient directly into alarge collection chamber via a6-foot patient tube (3/8" I.D.).As drainage fluids collect in thischamber, the nurse will recordthe amount of fluid that collectson a specified schedule. Hence,an easy-to-read, well calibratedcollection chamber is one ofthe most important featuresfor any new chest drainagesystem.

n Water SealThe water seal chamber, which is connected in series to thecollection chamber, allows air to pass down through a strawor narrow channel and bubble out through the bottom of thewater seal. Since air must not return to the patient, a waterseal is considered one of the safest and most cost effectivemeans for protecting the patient, in addition to being a veryuseful diagnostic tool. The water seal column is calibratedand acts as a water manometer for measuring intrathoracicpressure. As changes in intrathoracic pressure occur, fluctu-ation in the water level can be observed in the calibrated col-

6

umn. Such fluctuations provide theclinician an indication of how the patientis progressing. With the addition of anadvanced float valve at the top of thewater seal, a patient can also be protectedfrom the dangers of accumulating highvacuum pressures or high negativity,which can be induced from chest tubestripping or milking. Today’s moresophisticated systems provide suchpatient protection both manually andautomatically.

n Dry Suction ControlThe addition of suction improves therate of and flow of drainage, as well ashelps overcome an air leak by improvingthe rate of airflow out of the patient. Today’s advanced chestdrains incorporate dry suction control technology to maintainsafe and effective levels of vacuum to the patient. In similarfashion to how a traditional calibrated water chamber controlssuction, Atrium's precision dry suction control regulator

works by continuously balancing theforces of suction and atmosphere.Atrium's dynamic automatic controlvalve (ACV), located inside the regulator,continually responds and adjusts tochanges in patient air leaks andfluctuations in suction source vacuumto deliver accurate, reliable suction tothe patient. Suction pressure can be setto any desired pressure between -10cmH2O and -40cmH2O by simplyadjusting the rotary dry suction controldial. Expansion of the highly visiblebellows across the suction monitorwindow will readily confirm that suctionis operating.

7

The Atrium System

n All The Water You Need...And Less!From the beginning, Atrium has pioneered advances in waterseal design with compact chest drains that are smaller, userfriendly, and cost effective. We’ve continued ourcommitment to product innovation with the latest series ofAtrium Oasis™ dry suction water seal chest drains, featuring afamiliar water seal operating system with the enhancedperformance and convenience of dry suction control.Atrium's complete family of dry suction chest drains hasbeen carefully engineered to provide extraordinary adult andpediatric collection performance and satisfy today’s criticalneed for more cost effective blood management.

nWith pre-packaged water, system set up is fast andconvenient.

n Improved knock-over performance.

n Finger-tip suction control dial can be easily adjusted to anysuction setting between -10cmH2O and -40cmH2O for awide range of chest drainage applications.

n Advanced dry suction control regulator continually adjuststo changes in patient air leaks and fluctuations in hospitalwall suction, providing the ultimate in safety and reliability.

n Highly visible suction monitor bellows readily confirmssuction operation.

n Large, easy-to-read collection chamber numbers andgraduations provide the ultimate in patient drainageassessment.

n�Advanced controlled release float valve design providesautomatic high negative pressure relief.

n Filtered manual vent offers an additional method forcontrolling vacuum pressures when connected to suction.

n Blue tint water seal offers enhanced visibility for air leakdetection and patient pressure diagnostics.

8

9

PositivePressureRelease Valve

Easy-to-GripHandle In-line

Connector Multi-PositionHangers

PatientTubeClamp

PatientConnector

Swing OutFloor Stand

PatientPressureFloat Ball

SuctionMonitorBellows

DrySuctionRegulator

100%LATEX-FREE

Water SealChamber

CollectionChamber

Air LeakMonitor

SuctionPort

Manual HighNegativity Vent

NeedlelessAccess Port

n Continually Adjustable Dry Suction ControlAtrium’s precision dry suction control regulator providesaccurate, dependable suction for a wide range of chest

drainage applications.The state-of-the-artregulator designcontinually and auto-matically adjusts tochanges in patient airleaks and/or fluctua-tions in hospital wallsuction to help main-tain a more consistentvacuum level to thepatient. Suction pres-sure can be set to any

desired pressure level between -10cmH2O and up to a maxi-mum of -40cmH2O. Changing the suction pressure is easilyaccomplished by adjusting the rotary dry suction control diallocated on the side of the drain. Simply dial down to lowerthe suction setting and dial up to increase the suctionpressure setting.

n Suction MonitorBellows Atrium’s suction monitorbellows allows quick and easyconfirmation of vacuumoperation. Expansion of thebellows across the suctionmonitor window will confirmsuction operation.

10

Bellows expanded to s mark or beyondconfirms adequate suction operation.

Dial up toincreasesuction

Dial downto lowersuction

n Advanced Water Seal TechnologyAt the heart of every Atrium Oasis™ dry suction water sealchest drain is an advanced water seal design. Patient air leakassessment and system integrity are enhanced with Atrium'sblue tint water seal and superior knock-over protection. Thefully calibrated water seal and patient pressure float ball alsomake it easier to monitor changes in intrathoracic pressures.Together with our automatic high negative pressure relief andan easy-to-use filtered manual vent, patients now have theultimate protection from accumulating high negativepressure.

n�Proven Float Valve DesignAtrium’s high negativity float valve, with its unique controlledrelease action, enables any thoracic patient to draw as muchintrathoracic pressure as is required during each respiratorycycle. During prolonged episodes of extreme negative pres-sure (as with chest tube stripping), Atrium's controlled re-lease system will automatically relieve excessive highnegative pressure to a lower level.

n�Convenient System DisconnectionAnd Options ForAutotransfusionAll models are equippedwith in-line connectors.Atrium offers unlimitedflexibility for prescribingpost-op autotransfusionat any time. These tam-per-resistant, lockingpatient tube connectorsprovide convenientdisconnection after useor rapid in-line ATSblood bag attachment,when required.

11

n�Atrium Product Feature Summary

Feature Benefit Function

n Compact, n Easier to store, n� More environmentally responsible.Lightweight handle, and transport. Less waste is more cost savingsChest Drain Less packaging. for the hospital.Design

n Continually n Continually and n Regulator dial can be set to anyAdjustable automatically adjusts desired suction pressure betweenDry Suction to changes in patient air -10cmH2O and -40cmH2O.Control leaks and/or fluctuations Provides accurate, reliable suction

in hospital wall suction. control for a wide range of chestdrainage applications.

n Suction n Quick and easy n Large, brightly colored bellowsMonitor confirmation of suction expands across suction monitorBellows operation. window when suction is operating.

n*Pre-Packaged n With only the water seal n No more overfilled or underfilledWater to fill, system set-up is fast water seals. The ultimate in time

and convenient. and cost savings.

n Blue Tint n More efficient air leak n Water seal turns blue when filled.Water Seal detection and convenient Improves visibility.

monitoring of patientpressure.

n Graduated Air n Fast, easy detection n Air leak bubbling can range fromLeak Monitor and monitoring of 1 (low) to 5 (high) for monitoring

patient air leaks. patient air leak trends.

n High Negativity n Advanced design provides n Allows the thoracic patient to drawFloat Valve maximum patient as much intrathoracic pressure as

protection during deep required to complete respirationinspiration and gravity while maintaining the integrity ofdrainage. the water seal.

n Filtered n Preferred ergonomic n Provides effective manual ventManual Vent design is easy-to-use control when lowering height of

and offers maximum water seal column.filter protection.

n High Negative n Advanced float valve n Unique valve design offers aPressure automatically vents controlled release during episodesProtection high vacuum. of prolonged high negative

pressure.

12

*patented

Feature Benefit Function

n Positive n Tamper resistant positive n Integral to the system, this valvePressure pressure relief valve automatically prevents tensionProtection automatically protects pneumothorax during accidental

patient from accumulating suction line occlusion.positive pressure.

n Autotransfusion n Atrium provides numerous n Fast, convenient ATS bag use orCapabilities options for emergency or continuous ATS via infusion pump.

post-op autotransfusionon demand.

n In-Line Connector n Smooth, low-profile design n Connector provides convenienthas audible locking system disconnection or fastmechanism. in-line ATS bag attachment.

n Collection n� Improved collection n�Large collection windowChamber chamber design is graduations provide fast andGraduations easier to read. accurate volume assessment.

n�Maximum n� Fully recoverable water n�Water seal integrity is preservedKnock-over seal offers maximum during transport and accidentalProtection patient protection. knock-over, even when connected

to suction.

n Easy-to-Grip n� Comfortable design n�Makes patient ambulation and Handle facilitates hand-off. patient transport safer and more

practical than before.

n�Flexi-Hangers n� Accommodates today’s n�Flexible hangers (located inside thenewer bed designs. handle) allow drain to be hung from

a single point.

n�Swing Out n� Secure system placement n�Floor stand conveniently swingsFloor Stand during set up or on floor. out for maximum stability, closes

for transport.

n Complete n� Atrium produces a complete n�Atrium offers maximum costProduct Line family of dry suction chest efficiency with superior quality and

drain models for hospital- options for ATS, all with a familiarwide standardization, water seal operating system.including dual collection,pediatric, and ATS models.

n Needleless n In-line fluid removal. No n Connects to any standardAccess Sampling needle necessary. luer-lock syringe.Port

13

System Set Up

n Open PackageRemove non-sterile outer protective bag. Atrium chestdrains are wrapped in two layers of CSR wrap and shouldbe opened following hospital approved sterile technique.

n Requirements For Set UpA maximum of 50ml of water will be required. Followhospital’s protocol for type of water to be used. Sterilesaline should be used for ATS applications.

n Four Step Set UpSwing floor stand open for set up. For models equipped withan in-line connector, move the patient tube clamp closer tothe chest drain (next to the in-line connector) for set up con-venience and patient safety. Follow steps 1-4 and refer toeach model’s operating instructions for additional detailsconcerning system set up, operation, indications for use, andwarnings and cautions.

14

n Step 1Fill Water Seal To 2cm LineAdd 45ml of sterile water or sterile saline via the suction portlocated on top of the drain. For models available with sterilefluid, twist top off bottle and insert tip into suction port.Squeeze contents into water seal until fluid reaches 2cm fillline.

Once filled, water becomes tinted blue for improved visibilityof air leaks and convenient monitoring of patient pressures.

15

n Step 2Connect Chest Drain To PatientRemove patient tube connector cap and insert steppedpatient connector into patient’s catheter(s). Remove or cut offstepped connector for “Y” connector insertion. If desired,use of nylon bands around catheter and patient tubeconnections will assure an air-tight connection. Connectchest drain to patient prior to initiating suction.

n Step 3Connect Chest Drain To Suction Attach suction line to blue suction port on top of chest drain.

Suction SourceThe suction source should provide aminimum vacuum pres-sure of -80mmHg at 20 liters of air flow per minute for chestdrain operating efficiency at a suction control setting of-20cmH2O. The suction source vacuum should be greater than -80mmHg when multiple chest drains are connectedto a single suction source.

16

Indwellingchesttube

n Step 4Turn Suction Source OnIncrease suction source vacuum to -80mmHg or higher. Thesuction monitor bellows must be expanded to the smark orbeyond for a -20cmH2O or higher regulator setting. Theregulator control dial, located on the side of the drain, canbe adjusted to any suction setting between -10cmH2O and-40cmH2O. Dial down tolower the suction settingand dial up to increase.

Suction Monitor BellowsWhen the suction controlregulator is set at -20cmH2O or higher, thebellows must be expandedto the smark or beyondwhen suction is operating.If the bellows is observedto be expanded, but lessthan the smark , thesuction source vacuumpressure must be increased to -80mmHg or higher. For aregulator setting less than -20cmH2O suction (-10cmH2O),any observed bellows expansion across the monitor windowwill confirm suction operation. The bellows need not beexpanded to the smark for pressures less than -20cmH2O,just visibly expanded to confirm suction operation.

17

Turn suction source to -80mmHg orhigher. Bellows must be expanded to smark or beyond for -20cmH2O or higherregulator setting.

What To Check DuringSystem Operation

n Verifying Suction Operation ViaThe Suction Monitor BellowsThe bellows located in thesuction monitor will expandonly when suction is operat-ing. The monitor bellowswill not expand when suc-tion is not operating ordisconnected. The cali-brated smark allows quickand easy confirmation ofvacuum operation over awide range of continuouslyadjustable suction controlsettings.

n Increase Vacuum Source When Bellows IsNot Expanded To sMarkIf the bellows is observed to be expanded, but less than thesmark, the vacuum source pressure must be increased to-80mmHg or higher.

18

Bellows must be expanded to smarkor beyond for a -20cmH2O or higherregulator setting.

Increase suction source to-80mmHg or higher.

Normal suctionoperation for-20cmH2O orhigher.

Not enough vacu-um for -20cmH2Oor higher suctioncontrol setting.

n Changing Suction PressureChanging suction pressure is easily accomplished by adjust-ing the rotary dry suction control dial located on the side ofthe drain. Dial down to lower suction pressure and dial up toincrease suction pressure.

NOTE: When changing suction pressure from a higher tolower level,use of the manual high negativity vent after regu-lator adjustment will reduce excess vacuum down to thelower prescribed level.

n Recording Drainage VolumeThe collection chamber incorporates a writing surface witheasy-to-read fluid level graduations. Please refer to individualproduct for specific calibrations.

n Placement Of UnitFor optimum drainage results, always place chest drainbelow the level of the patient’s chest in an upright position.To avoid accidental knock-over, it is recommended to swingthe floor stand open for secure placement on floor or to hangthe system bedside with the hangers provided. Atrium’s uniquewater seal design provides maximum knock-over protectionagainst inter-chamber siphoning events, accidental spillover,and does not allow unrestricted atmospheric air back to thepatient when kept in an upright position.

19

n Verifying Water Seal OperationThe water seal must be filled and maintained at the 2cm levelto ensure proper operation and should be checked regularlywhen used for extended periods. As required, additionalwater may be added by syringe via the grommet located on theback. Fill to the 2cm line.

n Observing Changes In Patient PressurePatient pressure can be determined by observing the level ofthe blue water and small float ball in the calibrated water sealcolumn. With suction operating, patient pressure will equal

the suction control settingplus the calibrated water sealcolumn level. For gravitydrainage (no suction) patientpressure will equal thecalibrated water sealcolumn level only.

n High Negativity Float ValveAtrium's high negativity float valve, with its controlled releaseaction, enables any thoracic patient to draw as muchintrathoracic pressure as is required during each respira-tory cycle. During prolonged episodes of extreme negativepressure, Atrium's controlled release system will automaticallyrelieve excess vacuum toa lower, more desirablepressure level.

20

n Observing Water Seal For Patient Air LeaksAtrium Oasis™ chest drains offer superior air leak detection withrapid air leak assessment and improved visibility due to thetinted water. A patient air leak is confirmed when air bubbles areobserved going from right to left in the air leak monitor.

Continuous bubbling in the bottom of the water seal air leakmonitor will confirm a persistent air leak.

Intermittent bubbling in the air leak zone with float ball oscil-lation will confirm the presence of an intermittent air leak.

No bubbling with minimal float ball oscillation at bottom ofwater seal will indicate no air leak is present.

n Graduated Air Leak MonitorFor those models with a graduated air leak monitor, air leak bub-bling can range from 1 (low) to 5 (high). Air bubbles create aneasy to follow air leak pattern for monitoring patient air leaktrends.

n Sampling Patient DrainageSampling of patient drainage must be in accordance with approvedhospital infection control standards. Selected models include aneedleless luer port on the patient tube connector for samplingpatient drainage. Alcohol swab the luer port prior to syringe attach-ment (no needle). Fluid samples can also be taken directly from thepatient tube by forming a temporary dependent loop and insertinga 20 gauge needle at an oblique angle. Alcohol swab the patienttube prior to inserting syringe at a shallow angle. Do not puncturepatient tube with an 18 gauge or larger needle.

21

n Manual High Negativity Vent To manually lower theheight of the water sealcolumn or to lowerpatient pressure whenconnected to suction,temporarily depress thefiltered manual ventlocated on top of the drain until the float valve releases andthe water column lowers to the desired level. Do not usemanual vent to lower water seal column when suction isnot operating or when the patient is on gravity drainage.

n Positive Pressure Protection Atrium’s positive pressure release valve, located on top ofdrain, opens instantly to release accumulated positivepressure. Integral to the system,this advanced valve design istamper-resistant and offersmaximum air flow. Do notobstruct the positive pressurevalve.

n Swing Out Floor Stand Atrium’s floor stand swings open for convenient systemset up and secure placement on floor. It is recommendedthat the floor stand be closed during patient transit or whenunit is hung on bed.

n Multi-Position Hangers The multi-position hangersare easily lifted from insidethe handle. Press hangersinto handle when not in use.

22

Do not use when suction is not operating.

Lift touse

Push into lock

n In-Line Patient Tube Connector The locking in-line patient tube con-nector provides convenient systemreplacement, simple disconnectionafter use, and rapid in-line ATSblood bag attachment when required.The in-line connector must remainsecurely connected at all times dur-ing operation and patient connection.Do not separate in-line connectorprior to clamping off patient tubeclamp.

n Patient Tube ClampThe removable patient tube slide clamp provided with in-lineconnector models must remain open at all times duringsystem operation. It is recommended to move the patienttube clamp next to the in-line connector (closer to the chestdrain) for set up convenience and routine visual check.Do not keep patient tube clamp closed when system isconnected to patient. Tube clamp must be closed prior toin-line connector separation.

n Gravity DrainageFor gravity drainage applications, the drain should be placedbelow the patient’s chest in an upright position. Disconnectthe suction source vacuum line from the suction line port.

23

CAUTION:Keep clamp openat all times whensystem isconnected topatient

Move clampcloser to drain,next to in-lineconnector

n�System DisconnectionFor models equipped with an in-line connector, close thepatient tube slide clamp prior to disconnecting the chestdrain patient tube from patient. For maximum patientprotection, clamp off all indwelling thoracic catheters prior todisconnecting chest drain from patient.

Anatomy AndPhysiology Review

n Anatomy Of The ChestThe chest wall is composed of the ribs, sternum, andthoracic vertebrae and are all interlaced and covered withintercostal muscle to form a semi-rigid structure. The lowerboundary or floor of the thoracic cavity is known as thediaphragm, which is also composed of muscle.

Although the thoracic cavity contains two passagewayswhich are open to the outside environment, the esophagusand trachea, the cavity itself is an enclosed structure. Theinterior of the thoracic cavity can be divided into three dis-tinct areas: the mediastinum and two separate chambers foreach lung. The superior mediastinum consists of soft tissuewhich encloses the esophagus, trachea, heart, aorta, and

24

Right lungcavity Diaphragm Mediastinal

cavity

Left lungcavity

Chest wall

other major vessels. The mediastinum acts as a flexible parti-tion which extends from the front-to-back and top-to-bottom ofthe central portion of the chest.

The inside of the rib cage is lined by a membrane called theparietal pleura while the lungs are covered by another mem-brane called the pulmonary or visceral pleura. Under normalconditions, these two pleural surfaces slide against eachother allowing the lungs to expand and contract. These twosurfaces are closely held to one another, being separatedonly by a very thin film of lubricating fluid secreted by thepleura, called pleural fluid.

n Why The Lungs Are ExpandedA principal factor which keeps the visceral and parietal pleuraetogether and not separating is vacuum, commonly referred toas negative pressure. This negative pressure, or vacuum, isalways present during normal respiration with the membranesclosely intact under normal conditions. The presence ofnegative pressure between these two membranes is whathelps hold the visceral pleura in close contact with the parietalpleura at all times. Hence, negative pressure or vacuumaround the outside of the elastic lung is what keeps the lungin a fully expanded position, counteracting the lung’s normaltendency to shrink in size.

25

Parietalpleura

Pleuralspace

Visceralpleura

If air, fluid, or blood were to enter the space between thesetwo membranes, the space created is known as a pleuralspace and is an abnormal occurrence. When this occurs,thelungs can no longer fully expand with each inspiration andintense pain results, inhibiting the voluntary effort ofbreathing.

n The Mechanics Of BreathingRespiration is the cycle of inspiration and expiration inwhich air moves in and out of the lungs due to changes inpressure. When the diaphragm is stimulated by the phrenicnerve, it contracts and moves downward. With the help ofthe external intercostal muscles, the rib cage moves up andout. The lung itself expands because of the movement ofthe diaphragm and the chest wall. The surface tension ofthe pleural fluid together with the naturally occurring vacuumpressure induced by the pulling action of the diaphragm iswhat actually holds the pleural membranes together, thuskeeping the lungs fullyexpanded.

Under normal condi-tions, there is alwaysnegative pressure inthe pleural cavity. Thedegree of negativity,however, changes dur-ing respiration. Duringnormal inspiration,intrapleural vacuumpressure is approxi-mately -8cmH2O,while during expirationthe vacuum pressurefalls to -4cmH2O.With deep inspiration,intrapleural pressurescan be even more negative.

26

Inspiration -8cmH2O

-4cmH2OExpiration

Why Water Seal CDUsAre Usedn Clinical Needs For Chest Tube DrainageWhen the chest wall is opened either by surgery or chestinjury, the in-rush of air causes the vacuum in the patient’spleural cavity to escape and atmospheric air to enter theintrapleural space. Since the normal negative pressure orvacuum is no longer present, the lungs collapse as theydepend upon this negativity or vacuum to stay fully expandedup against the inside of the chest wall. When air enters orbecomes trapped inside the chest causing a pleural space,the lungs cannot fully expand, and the patient will experiencedifficulty in breathing. This condition is known as apneumothorax. This is a frequent occurrence after all thoracicand cardiac surgeries, as well as with most chest wallinjuries. Very often there is a combination of both air andblood present in this abnormal space, causing a similar effecton breathing. When blood collects in the patient’s pleuralspace, it is known as a hemothorax and when there is thecombination of both blood and air, it is known as ahemopneumothorax.

27

Pneumothorax

Hemopneumothorax

Tension pneumothorax is a more serious complication thatcan develop when air continues to leak from a hole in thelung directly into the pleural space and has no way toescape. As more and more air accumulates in the pleuralspace, pressure within this space rises significantly. If thepressure builds up enough, it causes a mediastinal shift,which means that the entire mediastinal area, including theheart and other structures, can be pushed toward theunaffected side. This reduces the size of the unaffected lungchamber, making it very difficult to breathe. A mediastinalshift can also be significant enough to collapse the unaffectedlung to a measurable degree and interfere with normal heartactivity. When the compressed lung becomes collapsed as aresult of a tension pneumothorax condition, a life-threateningsituation develops which requires immediate attention. Earlysigns of mediastinal shift may include an overexpandedchest, shallow gasping respiration, a shift of the tracheain the suprasternal notch, and changes in arterial pulse.Any one or all of these signs require prompt attention andemergency action by the nurse and/or physician. Normally,this would be accomplished with a procedure known asa thoracostomy.

28

Tension pneumothorax,mediastinal shift

Other conditions in the pleural cavity that may require chestdrainage intervention are pleural effusion and empyema.Pleural effusion is the accumulation of fluid within the pleuralcavity. The presence of lymph fluid is called chylothorax andis often clear, serous fluid. Empyema is a pleural effusionthat involves purulent material in the pleural cavity and isoften caused by pneumonia, lung abscess, iatrogenic con-tamination of the pleural cavity, or injury.

Mediastinal drainage is routinely required after all heartsurgeries, sometimes including pleural drainage. Mediastinaldrainage is required to prevent the accumulation of bloodand clots from taking up space in and around the pericardiacsac. If blood were left to accumulate in the mediastinalcavity, it would cause cardiac tamponade, resulting in cardiac distress and death.

The physician’s prescribed treatment for any of these clinicaldrainage situations are:

1. To remove the fluid and air as promptly as possible.2. To prevent evacuated air and fluid from returning into

the chest cavity. 3. To expand the lungs and restore the negative

pressure in the thoracic cavity back to its normal level.

29

Pleural effusion

What To CheckFor During CDU UseVery often, potential problems can usually be avoided byroutinely checking the patient, tube connectors, and drainagesystem at regularly scheduled intervals. Listed below are manyof those common problems that can be easily corrected:

30

n clot in chest tube insidepatient

n clot in the patient tube

n�dependent loop in patienttube with fluid

n kink in patient tube frombed rail or patient position

n partial dislodgement ofcatheter from patient

n partial disconnection ofpatient tube from chesttube connector

n�overfilled water seal (wateris above 2cm line)

n in-line connectors notproperly secured

n patient tube clamp may beclosed

n floor stand is not fullyopened

n�chest drain is not upright

n�chest drain is not positionedsufficiently below patient’schest

n suction monitor bellowsdoes not fully expandbecause source suctionfalls below the minimumoperating range or poorconnection

Chest Tube Placement

n�Chest Tube InsertionTo facilitate air and fluid evacuation post surgically, the sur-geon will insert a catheter or thoracotomy chest tube so thatthe chest tube eyelets are located inside the chest wall. Thesurgeon will usually suture the catheter loosely in place tofacilitate removal later on. Frequently two catheters are inserted, in which case one is placed near the apex to removeair while the other is placed in the lower part of the chestto remove any pooled blood.

Thoracotomy chest tubes are normally flexible, kink resis-tant, clear catheters which are inserted through the chestwall via a small incision. A tight intercostal fit is preferred tominimize small bleeders around the catheter and to maintainan air-tight seal. A radiopaque stripe helps the clinician iden-tify catheter placement and location of the “catheter eyes”during X-ray for maximum drainage efficiency.

8FR-12FR Infants, young children Typical16FR-20FR Children, young adults Chest Tube24FR-32FR Most popular adult sizes Sizes36FR-40FR Larger adult sizes

31

Common insertionsite for air

Common insertionsite for fluid

n�Chest Tube Nursing ResponsibilitiesAfter chest tube insertion, the connector end of the catheteris cut to length and the chest drain stepped connector isinserted. Such connections are often secured with nylonbands for added security and to assure an airtight tubingconnection.

Since two or more indwelling chest tubes are frequentlyattached to a single chest drain via a “Y” connector set up,it is important to ensure that all indwelling catheters areproperly tailored so as to not kink.

It is important to check the chest tube connections forsigns of air leaks, such as “hissing” sounds or bubbling inthe water seal. Also check the chest tube dressings andcondition of the tube itself, such as position or clotting inthe tube. If a tube accidentally pulls out, the insertion siteshould be quickly sealed with a petroleum gauze dressingto prevent air from entering the pleural cavity. The physicianshould be notified to assess the patient’s condition and todetermine whether or not a new tube will need to be insertedbedside.

32

Bands for added security

Incorrect Correct

Troubleshooting Guide

What should I do when the suction monitor bellowsis not expanded to the smark when the regulatoris set at -20cmH2O or higher?

The position of the bellows across the suction monitorwindow will alert the operator that the suction sourcehas fallen below the minimum operating range for the prescribed suction control setting. Simply increase the vacuum source to -80mmHg or higher. The suction monitor bellows must expand to the smark or beyondfor a -20cmH2O or higher suction regulator setting.

What should I do when the bellows does not fullyexpand to the smark after I increase the suctionsource vacuum?

Dry suction chest drains require higher levels ofvacuum pressure and air flow from the suction source

33

Q

A

Q

A

Not enough vacu-um for -20cmH2Oor higher suctioncontrol setting.

Normal suctionoperation for-20cmH2O orhigher.

Increase suctionsource to -80mmHgor higher.

to operate efficiently at each suction control setting as compared to traditional water controlled operating systems. The suction source should provide a minimum vacuum pressure of -80mmHg at 20 liters of air flow per minute for chest drain operating efficiency at a suction control setting of -20cmH2O. The suction source should be greater than -80mmHg when multiple chest drains are connected to a single suction source. If the bellows does not fully expand to the smark,it may simply be that the suction source is not functioning to its full potential to provide the minimum vacuum pressure or air flow required to “drive” the suction control regulator. Additionally, conditions may exist that can reduce, or “restrict” air flow from the suction source. A restrictive clamp, connector, or kink in the suction line tubing can potentially “starve” the chest drain of air flow. A leak in a connection or wall canister, along with extensive lengths of suction tubing can also reduce air flow to the unit.

To troubleshoot this situation, first check to be sure that all connections are air-tight. Inspect the suction tubing and connections for possible cracks, leaks, kinks, or occlusions. You may need to simply bypass a “leaky” wall canister. Try connecting the chest drain to a different suction source or wall regulator. When multiple chest drains are “Y” connected to a single suction source, if possible, reconnect the drainsto separate suction sources. Finally, replace the chest drain if you suspect the unit is cracked or damaged.

Does the bellows need to expand beyond thesmark for a -10cmH2O regulator setting?

No. For a regulator setting less than -20cmH2Osuction (-10cmH2O), any observed bellows expansionacross the monitor window will confirm suction operation. The bellows need not be expanded to the s�mark for suction pressures less than -20cmH2O, just visibly expanded to confirm suction operation.

34

Q

A

How do I confirm my patient has an air leak whenthere is:

n�No bubbling in the water seal?

If there are no air bubbles observed going from rightto left in the air leak monitor, there is no patient air leak.In order to confirm that your patient’s chest catheter(s) are patent, temporarily turn suction off and check for oscillation of the patient pressure float ball in the water seal column coinciding with patient respiration.

n�Bubbling present in the water seal?

Whenever constant or intermittent bubbling ispresent in the water seal air leak monitor, this will con-firm an air leak is present. Oscillation of the patient pressure float ball at the bottom of the water seal without bubbling will indicate no apparent air leak. To determine the source of the air leak (patient or catheter connection), momentarily clamp the patient tube close to the chest drain and observe the water seal. If bubbling stops, the air leak may be from the catheter connections or the patient’s chest. Check the catheter connectors and patient dressing for a partially withdrawn catheter. If bubbling continues after temporarily clamping the patient tube, this will indicate a system air leak requiring system replacement.

What does it mean when the small float ball islocated at the bottom of the water seal column?

If the small float ball is located and oscillating atthe bottom of the water seal column with no bubbling,there is no apparent patient air leak. However, the water seal should be carefully monitored for the presence of an occasional or intermittent air leak.

35

Q

A

A

A

Q

How do I lower the water seal level?

Changes in your patient’s intrathoracic pressurewill be reflected by the height of the water in the waterseal column. These changes are usually due to mechanical means such as milking or stripping patient drainage tubes, or simply by deep inspiration by your patient after all air leaks have subsided. If desired, the height of the water column and patient pressure can bereduced by temporarily depressing the filtered manual vent located on top of the drain, until the float valve releases and the water column lowers to the desired level. Do not lower water seal column when suction is not operating, or when patient is on gravity drainage.

What happens when the water rises to the topof the water seal float valve?

The water seal column is a diagnostic manometerfor monitoring your patient’s intrathoracic pressure.When intrathoracic pressures increase, causing the water to rise to the top of the water seal float valve, the ball floats up and “seats” up against a valve seat. This valve seat has been carefully engineered to allow a certain amount of water to pass through it during a precise amount of time. When vacuum pressures greater than -20cmH2O on gravity or -40cmH2O on suction occur for an extended period of time,water will pass through the valve seat and float valve to allowthe water seal to release automatically. The benefit of Atrium's controlled releasedesign is that duringnormal or deep inspiration, thefloat valve will float up and downwith each respiratory cycle, notallowing the water seal to release.

36

QA

A

Q

This enables thoracic patients to draw as much intrathoracic pressure as they may require duringeach respiratory cycle.

Is it normal for the patient pressure float ball tofluctuate up and down (tidal) near the bottom ofthe water seal column?

Yes. Once your patient’s air leak is resolved, you willgenerally observe moderate tidaling in the water sealcolumn. Increases in intrathoracic pressure will cause the water level to rise (the ball rises) during patient inspiration and will lower or decrease (the ball drops) during expiration. This diagnostic tool will help to confirm patency of your patient’s catheter(s).

How do I determine patient pressure witha dry suction chest drain?

Whether a traditional wet or dry suction operatingsystem, one cannot overemphasize the importanceof the calibrated water seal column when it comes to diagnosing the patient’s condition or monitoring normal system operation. Patient pressure can be determined by observing the level of the blue water andsmall float ball in the calibrated water seal column. With suction operating and the bellows expanded across the suction monitor window, patient pressure will equal the suction control setting (read directly fromthe regulator dial) plus the calibrated water seal columnlevel. For example, when the suction monitor bellows is expanded to thesmark or beyond to confirm a-20cmH2O suction setting, and the calibrated water sealcolumn reads -15cmH2O, patient pressure is -35cmH2O(-20cmH2O + -15cmH2O = -35cmH2O). For gravity drainage (no suction) patient pressure will equal the calibrated water seal column only.

37

Q

A

A

Q

38

Should the manual vent be used duringgravity drainage?

No. It is not recommended to depress the manual ventduring gravity (no suction) drainage.

If the chest drainage system has been knockedover, can I use it and what should I do?

After a chest drainage system has been knocked over,set it upright and immediately check the fluid level ofthe water seal for proper volume. Atrium provides a convenient self-sealing diaphragm for access by a 20 gauge or smaller needle and syringe to adjust the water level in the water seal chamber, if required. Alcohol swab the needle access area and aspirate any overfill that may have occurred. If the water seal has an inadequate fluid level, simply replace the lost volume. If a significant amount of blood has enteredthe water seal, it may be advisable to change the system for a new one.

How do I dispose of the system?

Disposal of system and contents must be in accordance with approved hospital infection controlstandards.

AQ

Q

A

Q

A

Notes

39

CUSTOMER SERVICEIf a question or need arises for customer service, productinformation, or to request inservice educational material,we invite you to call or FAX Atrium’s hotline anytime.

In the U.S.A. 1-800-528-7486Outside the U.S.A. 603-880-1433FAX 603-880-6718www.atriummed.com

Atrium Medical Corporation5 Wentworth DriveHudson, New Hampshire 03051 U.S.A.

© Atrium

Medical Corporation 2009 Made and printed in U.S.A. 8/09 370029G