RSPT 2325 Diagnostics Unit 4: Case Studies in Chest Tubes and Bronchoscopy KEY

RSPT 2325 Diagnostics Unit 4: Case studies in Chest tubes and Bronchoscopy KEY Name: Date: 2009

NOTE: Clarification of VASO-VAGO or VAGO-VAGO reactions:  According to Egan’s a hazard of suctioning is “reflex bradycardia due to vagal stimuli “  According to Mosby’s dictionary VAGOVAGAL is reflex bradycardia caused by tactile stimulation of the trachea or laryngeal structures  According to the Mayo Clinic staff webpage: VASOVAGAL reaction is a reflex bradycardia and hypotension resulting in syncope that is triggered by stress –such as a painful medical procedure  This means that vasovagal reaction is a hazard of Thoracentesis which can be minimized by pain medication and sedation  And a vagovagal reflex is obviously a hazard of bronchoscopy Case study # 1 Patient is a 35 YO BF with a 18 month-long history of recurrent pneumonia. She has been on PO antibiotics and cough syrup for weeks without resolution. HR 115, RR 23 BP 129/85 mmHg. Temp 38 oC  On inspection, you see a thin lady with cyanotic lips. She is alert and voices frustration over her health problems. She has some mild intercostal retractions and no flaring during breathing  On percussion, there is dullness over the RML  On palpation there is poor chest wall movement over the right chest. There is tenderness on inspiration over the right basal chest.  BBS reveal rhonchi in the RUL, and crackles in the RML. There are no wheezing 1. Recommend further assessment tools for this patient. a. Assess Sp02 or ABG b. Get PA and lateral chest film c. Interview patient regarding history of current illness d. Sputum culture and sensitivity, AFB, gram stain The doctor orders an ABG, EKG and PA and lateral chest film with the following results. pH PaC02 HC03- Pa02 7.42 36 23 59 X-ray: fluffy opacities in the RUL with some atelectasis and consolidation in the RML. There is blunting of the costophrenic angle in the right chest EKG: sinus tachycardia 2. At this point what therapeutic actions do you want to take? a. Start nasal cannula at 2 LPM; follow up with Sp02 in 30 minutes b. Start SVN with mucolytics/Beta II agonists c. Avoid CPT because there is an effusion in the right chest i. Because we need to mobilize secretions, we could follow the SVN with adjuncts to CPT which would not spread the effusion around the chest— assuming there is no chance that the effusion is blood—in which case the application of vibration or Positive pressure on the airway might be contraindicated

The doctor decides to perform a needle aspiration of the effusion. 3. How do you prep the patient? a. Mild IV sedation to prevent vasovago reflex and pain during procedure b. Place pulse oximeter on finger c. Baseline assessment of VS, BBS and visual s/s of increased WOB d. Lead II EKG monitor e. Baseline PA or AP chest film f. Get NRM and mask /bag/valve and 02 for emergencies & check function of bag g. Pull Crash cart to the area 4. What studies need to be performed on the sample if the MD wants to assess the patient’s infection a. Specific gravity b. CBC of fluid c. culture pleural fluid for C&S, d. gram stain e. Acid Fast Bacilli AFB [effusions common in TB] 5. What hazards does this patient face during the Thoracentesis? a. Pneumothorax or hemothorax, subcutaneous hematoma b. Infection c. pain at the site, d. cough, chest pain, e. vasovagal reflex bradycardia & hypotension f. re-expansion (unilateral) pulmonary edema, g. hypovolemia which could lead to hypotension, h. hypoxemia i. laceration of near-by structure 6. How much fluid can the doctor remove in 30 minutes; why? a. No more than 1-1.5 liters within 30 minutes because the buildup of dangerous negative pressures in excess of -20 cmH20 can cause pulmonary edema 7. If the doctor decides to place a chest tube, describe the exact spot on the chest that needs to be

prepped and draped for this problem:

a. On right chest, the mid-axillary line at the level of 5th to 7th rib

8. How deep should the doctor push the chest tube?

a. Until the last fenestration on the chest tube is 3 cm past the insertion point

9. While the patient is breathing spontaneously what do you see in the chest tube while she is

breathing?

a. Because the patient is breathing spontaneously we would see the fluid level in the chest tube be pulled toward the patient chest on inspiration

10. Describe the three bottles [chambers] and their uses.

a. The first chamber collects the drainage from the chest. It is closest to the chest. b. The second chamber contains the water seal that prevents the patient from pulling air into the chest c. The last is the suction bottle that is attached to the suction regulator, although it is the water level here that provides the maximal level of suction

After three days of IV antibiotics, Q 4 hr, PRN at night SVN with 2.5 mg Albuterol in 3 ml 10% Mucomyst followed by chest percussion and postural drainage, and 2 LPM nasal cannula you see that the patient’s VS are unchanged, the Sp02 is 91% on 2 LPM. The X-ray shows that the consolidation is unchanged but that the effusion is gone. The chest tube is present

11. What do you recommend regarding the chest tube?

a. Once the patient is draining less than 100 ml/day we can remove the chest tube. Some MD recommend clamp it prior to pulling it out 12. The doctor decides to pull the chest tube after clamping it for several hours. He gets a chest x-

ray after the tube is clamped; why?

a. An AP chest film to is used to assess the possible recurrence of the effusion or the occurrence of a pneumothorax if air entered the chest during removal of the chest tube 13. While the doctor is pulling the chest tube out, he will tell the patient to take a deep breath in

and cough when he tells her—why?

a. He want positive pressure in the chest to shove air out of the hole rather than suck it into the hole- this will prevent a pneumothorax A few hours after the chest tube has been pulled, the patient has VS that are unchanged and Sp02 is 93% on 3 LPM. A chest film is done in which we see that the effusion is gone, but the consolidation persists in the RML. 14. If the doctor decides to perform a bronchoscopy what are the hazards?

a. Hypoxemia from acute airway occlusion that could lead to cardiac arrythmia b. Loss of consciousness during the conscious sedation procedure/loss of ability to protect the airway even loss of ventilatory drive c. Infection from the bronchoscope d. Bleeding with biopsy or brushing e. Pneumothorax from biopsy f. meth hemoglobin or seizures as a side effect side effect of lidocaine g. reflex bronchospasm/coughing from tactile stimulation h. reflex bradycardia from tactile stimulation i. vomiting and aspiration

15. Is this patient at increased risk for any of these hazards?

a. Already mildly hypoxic b. Already weaken by prolonged infection- would not handle a new infection too well 16. 8 hours before the bronchoscopy, we need to do what?

a. Patient NPO so vomiting and aspiration not a complication 17. 2 hours before we need to do what?

a. Systemic sedation & atropine to keep HR up to minimize chance of reflex bradycardia

18. About how far down the airways can the doctor send the bronchoscopy tube

a. 5th and 6th generation of airways in adults

19. What appliances will he want if he wants to collect tissue for cultures?

a. Brushes b. Needle for transbronchial biopsy c. Irrigate and suction equipment for washings

20. If he decides to lodge the end of the ‘scope into the distal airway in the RML and send 50 or

more ml of normal saline into the area, what do we call this procedure?

a. Broncho-alveolar lavage BAL procedure

21. If he decides that he wants to collect a sample via a brushing, do you get a sheathed brush or an

unsheathed brush—explain your answer.

a. sheathed brush to prevent cross contamination from upper airways or bronchi that the bronchoscope passes through. We will keep the brush sheathed by wax on the way down to the area we need to sample. After the brushing is done we retract the brush into the sheath to protect the tip from coming in contact with other areas of the lung.

Case study # 2

Your patient is a 55 YO WM with is history of recent coughing blood-stained secretions. His VS are HR 99 BPM. RR 15 BPM, he is afebrile, BP 119/80. He has no retraction, no flaring. BBS show only a single expiratory wheeze over the upper portion of the LUL. There is dullness to percussion over the left basal chest wall. On chest film there is slight hyperinflation over the apical portion of the LUL and a small effusion is found with lateral decubatis chest film. His bleeding times are within normal. 1. How would you assess this patient at this time? a. Get sputum for cytology b. Get Sp02 to r/o hypoxemia

2. If the doctor wants to perform a needle aspiration of the chest, where would the needle go? a. Left chest at mid-axillary line at 5-7th intercostal space

3. What hazards might we worry about with this patient? a. Pneumothorax h. re-expansion (unilateral) pulmonary b. Hemothorax edema, c. Infection i. hypovolemia, d. subcutaneous j. hypoxemia that can hematoma, persists for several e. pain at the site, hours, f. cough, chest pain, k. laceration of near-by g. vaso-vagal reflex structure

4. If the doctor aspirates fluid, what type of tests would you perform to find evidence of a malignancy? a. Cytology b. Glucose level c. WBC 5. What chemical would be in the sample cup that goes to the lab for the above studies? a. Cytology samples need to be fixed in a formaldehyde type of fixative

A needle aspiration is done and 100 ml of sangoserous fluid is collected.

6. What studies are needed to document a hemothorax? a. While the sample visibly contains blood, we need to get a spun crite on the sample, if it is at least 50% of the blood’s crite level we have frank blood that requires complete removal 7. If the glucose levels of the plural fluid is lower than expect, for what problem is this a sign? a. Low glucose in the pleural fluid implies there is malignancy present

8. If the protein levels are more than 3 gr/dL, is this a transudate or an exudates? a. More than 3 gr/dl implies that the fluid came from between cells. It is a exudative effusion.

9. Is it likely that this patient’s effusion is due to congestive heart failure? a. CHF produces transudates, so we can rule out congestive heart failure. Also there is no cardiomegally found on the chest film, nor any other s/s of CHF. b. While the patient has dullness to percussion this is explained by the effusion . c. We also expect a degree of increased WOB with CHF—this we don’t see

10. Is it likely that this patient’s effusion is due to pneumonia? a. He is afebrile so unlikely, but we need to culture the samples just in case

11. Is it likely this patient’s effusion is due to cancer? a. Likely, with his history of recent bleeding & the appearance of an effusion without s/s of pneumonia or CHF