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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:
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According to Egan’s a hazard of suctioning is “reflex bradycardia due to vagal stimuli “
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According to Mosby’s dictionary VAGOVAGAL is reflex bradycardia caused by tactile stimulation
of the trachea or laryngeal structures
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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
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This means that vasovagal reaction is a hazard of Thoracentesis which can be minimized by pain
medication and sedation
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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 38oC
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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
7.42
PaC02
36
HC0323
Pa02
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 xray 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
b. Hemothorax
c. Infection
d. subcutaneous
hematoma,
h. re-expansion
(unilateral) pulmonary
edema,
i.
hypovolemia,
e. pain at the site,
j. hypoxemia that can
persists for several
hours,
f. cough, chest pain,
k.
g. vaso-vagal reflex
laceration of nearby 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.
Case study unit 4 page 6
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