Comments on: The Patient is Ballooning Up… http://lifeinthefastlane.com/2010/01/pulmonary-puzzle-006/ Emergency Medicine education blog Wed, 23 May 2012 14:50:33 +0000 hourly 1 http://wordpress.org/?v=3.3.2 By: Mathias Tschopphttp://lifeinthefastlane.com/2010/01/pulmonary-puzzle-006/#comment-2265 Mathias Tschopp Mon, 04 Jan 2010 10:40:45 +0000 http://lifeinthefastlane.com/?p=10676#comment-2265 Yep, we basically agree. I would sum it up like that - If mechanically ventilated, don't put a tight seal around a drain, it doesn't matter if air leaks out around the drain, it's a security in case the drain is not letting enough air out or if it kinks. Air that stays trapped inside the thoracic space will eventually cause problems (tension, subcutaneous emphysema), so tight is not good. Yep, we basically agree. I would sum it up like that
- If mechanically ventilated, don’t put a tight seal around a drain, it doesn’t matter if air leaks out around the drain, it’s a security in case the drain is not letting enough air out or if it kinks. Air that stays trapped inside the thoracic space will eventually cause problems (tension, subcutaneous emphysema), so tight is not good.

]]> By: Chris Nicksonhttp://lifeinthefastlane.com/2010/01/pulmonary-puzzle-006/#comment-2264 Chris Nickson Mon, 04 Jan 2010 10:20:08 +0000 http://lifeinthefastlane.com/?p=10676#comment-2264 Thanks for your comments Mathias.RE: “try to obtain an adequate seal around the ICC insertion sites: close the wounds with sutures, seal with petroleum gauze and apply an occlusive dressing."I agree this is not going to stop air leaking from the pleural cavity into the subcutaneous tissues. However it may stop air being sucked in from the outside - although this is less likely to occur with positive pressure ventilation.After the subcutaneous emphysema has already developed, placement of new ICCs (that work) is the key intervention. What is done about the old holes is much less important - though they have to close up some time!RE: “avoid making an excessive hole on ICC insertion (should be large enough to admit a finger).”Avoiding an excessive hole initially means that intrapleural air has to pass through, rather than around, the intercostal catheter and makes the development of subcutaneous emphysema less likely. If a pneumothorax persists due to ongoing air leak then another ICC should be inserted, or further bronchoscopic and surgical measures considered.Regards, Chris Thanks for your comments Mathias.

RE: “try to obtain an adequate seal around the ICC insertion sites: close the wounds with sutures, seal with petroleum gauze and apply an occlusive dressing.”

I agree this is not going to stop air leaking from the pleural cavity into the subcutaneous tissues. However it may stop air being sucked in from the outside -- although this is less likely to occur with positive pressure ventilation.

After the subcutaneous emphysema has already developed, placement of new ICCs (that work) is the key intervention. What is done about the old holes is much less important -- though they have to close up some time!

RE: “avoid making an excessive hole on ICC insertion (should be large enough to admit a finger).”

Avoiding an excessive hole initially means that intrapleural air has to pass through, rather than around, the intercostal catheter and makes the development of subcutaneous emphysema less likely. If a pneumothorax persists due to ongoing air leak then another ICC should be inserted, or further bronchoscopic and surgical measures considered.

Regards,
Chris

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