An air leak is a sure-fire reason to keep a chest tube in place. Fortunately, many air leaks are not from the patient’s chest, but from a plumbing problem. Here’s how to locate the leak.
To quickly localize the problem, take a sizable clamp (no mosquito clamps, please) and place it on the chest tube between the patient’s chest and the plastic connector that leads to the collection system. Watch the water seal chamber of the system as you do this. If the leak stops, it is coming from the patient or leaking in from the chest wall.
If the leak persists, clamp the soft Creech tubing between the plastic connector and the collection system itself. If the leak stops now, the connector is loose.
If it is still leaking, then the collection system is bad or has been knocked over.
Here are the remedies for each problem area:
Patient – Take the dressing down and look at the skin entry site. Does it gape, or is their obvious air hissing and entering the chest? If so, plug it with petrolatum gauze. If not, the air is actually coming out of your patient and you must wait it out.
Connector – Secure it with Ty-Rap fasteners or tape (see picture). This is a common problem area.
Collection system – The one-way valve system is not functioning, or the system has been knocked over. Click here for an example. Replace it immediately.
Note: If you are using a “dry seal” system (click here for more on this) you will not be able to tell if you have a leak until you fill the seal chamber with some water.
The original chest tube collection system traditionally consisted of three chambers. The picture above shows the classic three bottle system (which I actually remember using during residency). On the left is the suction control bottle that determines how much suction is applied to the patient. The middle bottle provides one way flow of air out of the patient, the so-called water seal bottle. Finally, the right bottle collects any fluid from the pleural space.
Collection systems used in hospitals are much more tidy than this, wrapping all three into one modular unit. However, if you look closely you can identify parts of the system that correspond to each of the bottles.
The problem with the older systems is that they typically require water in the “water-seal” chamber to maintain one-way flow out of the patient. If this chamber is compromised by knocking the system over (see this post), air may be able to enter the patient’s chest, giving them a big pneumothorax.
Management of chest tube collection systems by EMS is tough. It’s very easy to tip the system during air or ground ambulance runs, putting the patient at risk. Some manufacturers have developed so called “dry-seal” systems that use a mechanical one-way valve to avoid this problem.
I have not been able to use one of these systems yet. Here is my take on the pros and cons:
Pro – immune to tip-over and malfunction of the water-seal chamber
Con – more difficult to detect an air leak. Current models require either injection of a small quantity of water, tipping the system, or converting to a water-seal system.
Con – no literature regarding safety of this relatively new technology
Bottom line: Looks like a great idea to me, especially for EMS use. Once they get to the hospital, the unit can be changed to a water-seal system or a larger dry-seal system with the water injection port inthe dry-seal chamber.
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