1. Participate in intrahospital patient transport (Code: III I3b) [Difficulty: ELE: R, Ap; WRE: An]

2. Participate in land or air patient transport outside of the hospital (Code: III I3a) [Difficulty: ELE: R; WRE: Ap, An]

Be prepared to perform, during patient transport, all the respiratory care practices and procedures that have been described in this and other texts. It is extremely important that all equipment and supplies be accounted for before leaving the patient’s room for the next location. This is especially true if the patient is being moved to another hospital. Obviously, once interhospital transport is under way it is not possible to obtain an item that was forgotten. To help ensure that this does not happen, it is wise to have a checklist of everything that may be needed. In addition, all equipment must be checked for proper function. Calculate the duration of the oxygen cylinders at expected liter flows. Make sure that batteries and light bulbs work and have spare batteries and light bulbs.

If mechanical ventilation will be needed, select a unit that is lightweight and portable and has solid-state circuitry. For intrahospital transport, many respiratory care departments use pneumatically powered units. Typically, for interhospital transport, an electrically powered unit is selected. Make sure that it can be powered by both alternating current (AC) and direct current (DC) from batteries. If the ventilator will be used for a helicopter or unpressurized cabin fixed-wing aircraft, it must be able to deliver an intermittent mandatory ventilation (IMV)/synchronous intermittent mandatory ventilation (SIMV) mode through a demand valve rather than through a reservoir system. The ventilator controls and positive end-expiratory pressure (PEEP) should not be adversely affected by changes in atmospheric pressure during ascent and landing. Be prepared to provide ventilatory support with a bag-mask system if the mechanical ventilator should fail.

3. Participate in the medical emergency team (MET) (e.g., rapid response team) (Code: III I3d) [Difficulty: ELE:R, WRE: Ap, An]

Respiratory therapists need to be prepared to respond to individual emergency cases such as a cardiopulmonary resuscitation (CPR) or trauma victim. In addition, there are three mass casualty disaster scenarios that would require respiratory therapists to help care for a large number of casualties. These could be accidental or terrorism incidents.

The first is airborne chemical exposure to the lungs and skin. This could include lung-damaging agents (e.g., ammonia, chlorine, and phosgene gases); blistering agents of the skin, eyes, and mucous membranes (e.g., sulfur mustard [mustard gas] and phosgene); blood agents that block oxygen’s metabolism (e.g., hydrogen cyanide and cyanogen chloride); and nerve agents that block the breakdown of acetylcholine (e.g., organophosphate pesticides). In all cases, the first action is to remove the victim from the toxic area. First responders must wear a hazardous materials suit to protect themselves before entering the toxic area to remove any victims. Once a victim is taken to a safe area, specific treatment is based upon the type of chemical exposure. Then the victim will receive other supportive measures such as supplemental oxygen, airway management, and mechanical ventilation.

Second is exposure to airborne infectious agents such as the viruses that cause avian flu and severe acute respiratory syndrome (SARS) or the spores that cause anthrax. In these cases the victim must be treated by caregivers who are wearing personal protective devices such as an N95 mask or a powered air protection respirator (PAPR). See Chapter 2 for the guidelines on airborne infection control precautions.

The third scenario would be trauma from explosion, gun fire, or train wreck, for example. The most severely injured victims would have trauma to the head, neck, chest, and/or abdomen. Many would require intubation and mechanical ventilation. Airway management and intubation are covered in Chapters 12 and 18; mechanical ventilation is covered in Chapters 15 and 16.

4. Participate in disaster management (Code: III I3c) [Difficulty: ELE:R, WRE: Ap, An]

Respiratory therapists are an important group of health care professionals who respond to local emergencies and take part in mass casualty/disaster planning. They should be part of a hospital’s disaster management team. The local hospital is linked to a regional disaster management team that further connects to the state system and finally the national system. Currently, in anticipation of a catastrophe that could overwhelm a local or regional medical system, the federal government has established the Strategic National Stockpile (SNS). If there should be a locally overwhelming need for supplies or equipment, the state government would submit a request to the appropriate division of the Centers for Disease Control and Prevention. The following items can be dispatched by the SNS and received within 1 day:

Other respiratory care related supplies and oxygen supply systems must be provided locally. Be prepared to perform any and all respiratory care practices and procedures listed in this book or in other respiratory care textbooks.

1. Assist with moderate (conscious) sedation (Code: IIIJ7) [Difficulty: ELE: R, Ap; WRE: An]

The phrase moderate (or conscious) sedation refers to the administration of a sedative agent that calms a patient during a medical procedure (for example, cardioversion or bronchoscopy) but does not cause the patient to lose consciousness. The sedated patient can be stimulated to cooperate and follow commands during the procedure. Typically the patient has no memory of the procedure after it is completed.

Medications in the benzodiazepine group are preferred for conscious sedation and given intravenously. Currently midazolam (Versed) is preferred but diazepam (Valium) is also commonly used. When the patient’s procedure is completed, these medications can be reversed by intravenous flumazenil (Romazicon). Another option is to intravenously administer the narcotic agent fentanyl (Duragesic, Sublimaze) for rapid sedation. After the procedure is completed, naloxone (Narcan) is given intravenously to reverse the effects of fentanyl. There is more discussion of these and other sedative agents in Chapter 9, Pharmacology.

The respiratory therapist must be prepared for the possibility of the patient being overdosed with a sedative agent. This could result in a decreased respiratory rate and tidal volume or apnea. Safety guidelines require either a nurse or a respiratory therapist to monitor the patient’s breathing, pulse oximetry values, heart rate, blood pressure, and electrocardiogram. The therapist must be prepared to administer supplemental oxygen or begin bag-mask ventilation if needed.

2. Assist with the insertion of venous or arterial catheters (WRE code: IIIJ6) [Difficulty: WRE: An]

Chapter 5, Advanced Cardiopulmonary Monitoring, contains discussions on preparation, care, and maintenance of central venous, arterial, and pulmonary artery lines. Review the chapter if needed.

Each hospital or physician may have a prescribed way that the catheter insertion procedure is performed. The general steps are listed here:

3. Assist with ultrasound (ELE code: IIIJ9) [Difficulty: ELE: R]

The ultrasound (also called a sonogram or ultrasonography) procedure uses a transducer to send soundwaves through the soft tissues of the body. A lubricating gel is placed on the skin so that there is good sound transmission from the transducer into the patient. Depending on the density of the tissues and fluids, the soundwaves bounce off and are received back to the transducer. The sound energy is converted to electrical energy to produce a two-dimensional image of the various organs. Ultrasound can be very useful in the following areas of interest to respiratory therapists:

Note that the lungs themselves cannot be properly imaged with ultrasound because they are air-filled. The ultrasound procedure is noninvasive and safe with no patient side effects.

4. Assist with cardioversion (Code: IIIJ8) [Difficulty: ELE: R, Ap; WRE: An]

Cardioversion (or countershock) refers to deliberately sending a direct current (DC) electrical shock through the patient’s heart. Its purpose is to suppress an abnormal heartbeat so that the normal pacemaker at the sinoatrial (SA) node assumes control. This is accomplished if a great enough electrical current is sent through the chest wall to cause the depolarization of a critical mass of myocardial cells. After this, the SA node should take over as the pacemaker, provided that the heart muscle is oxygenated and not too acidotic. Two different types of cardioversion exist: defibrillation (also called unsynchronized cardioversion) and synchronized cardioversion. Both were introduced in Chapter 11 for the treatment of specific arrhythmias.

Defibrillation is performed in an emergency situation (see Figure 11-41). Patients who need to be defibrillated include those who have ventricular tachycardia or ventricular flutter (see Figures 11-38 and 11-39) when they are pulseless, unresponsive, or hypotensive or patients who have pulmonary edema and ventricular fibrillation (see Figure 11-40). Because the fastest possible action is needed, no attempt is made to synchronize the defibrillation shock with the heart’s rhythm. While cardiopulmonary resuscitation (CPR) is being performed, the defibrillator unit is prepared. The defibrillating paddles (large positive and negative electrodes) are placed on the patient’s right anterior and left lateral chest wall. The physician or other qualified person (respiratory therapist, registered nurse, or paramedic) performing the defibrillation should call out, “Stand clear.” All other medical personnel should stand back from the patient and the bed and not touch anything that is electrically grounded. When the buttons on the paddles are pushed, the shock is administered. If it is successful, the patient’s heartbeat returns to normal sinus rhythm. If the initial shock is unsuccessful, CPR is continued. The defibrillator is then recharged for another attempt as quickly as possible. Box 18-1 shows the sequence of increasingly more powerful countershocks that can be given.

Synchronized cardioversion is similar in some ways to defibrillation. An electrical shock is sent by two paddles through the heart to suppress paroxysmal atrial tachycardia, atrial flutter, atrial fibrillation, or hemodynamically stable ventricular tachycardia (see Figures 11-25, 11-26, and 11-27) so that the SA node assumes control. Its major difference from defibrillation is that the electrical shock is administered automatically by the defibrillator after an R wave is recognized by the electrocardiogram (ECG) monitor (see Figure 11-5). The ECG electrodes must be in place and the best lead (often lead II) selected to show a clear, strong, upright R wave. The defibrillator unit is programmed for synchronized cardioversion. The physician holds the paddles on the patient’s right anterior and left lateral chest wall. When the discharge buttons are pushed on the paddles, the shock is sent after the next R wave is identified by the ECG monitor.

Cardioversion is not considered an emergency; however, it is performed as quickly as possible so that the patient does not stay in the abnormal rhythm any longer than necessary. Synchronized cardioversion is performed only if medical treatment with antiarrhythmia drugs or carotid artery massage has no effect. Because these patients are usually conscious, they should be sedated with diazepam (Valium), midazolam (Versed), or a similar medication. Patients who are hypotensive or already unconscious should not be sedated.

The respiratory therapist’s role in cardioversion may include the following:

5. Bronchoscopy

Bronchoscopy is a procedure that involves looking directly into the patient’s tracheobronchial airways. The physician can perform a number of diagnostic and therapeutic tasks under direct vision. (See Box 18-2 for uses, limitations, and risks of bronchoscopy.)

d. Manipulate a bronchoscope by order or protocol (Code: IIA27) [Difficulty: ELE: R; WRE: Ap, An]

1. Get a bronchoscope for the planned procedure

The rigid bronchoscope is a straight, hollow, stainless-steel tube (Figure 18-1). It has a distal light source so that the airway can be seen and a side port for providing oxygen or mechanical ventilation to the patient. The right and left mainstem bronchi can be observed by passing a mirror through the main channel. A hook or net can be passed through the main channel into the trachea or either bronchus to remove a foreign body. The rigid bronchoscope is preferred for the treatment of massive hemoptysis or to remove a foreign body.

Figure 18-1 A rigid tube bronchoscope being inserted into a patient’s trachea. Note how the head and neck must be hyperextended.

(From Simmons KF: Airway care. In Scanlan CL, Spearman CB, Sheldon RL, editors: Egan’s fundamentals of respiratory care, ed 5, St Louis, 1990, Mosby.)

Flexible fiberoptic bronchoscopy (FFB) uses a smaller diameter flexible tube with two sets of fiberoptic bundles that shine light into the airway and allow viewing of the airway. It has gained wide popularity because it is better tolerated by the patient and allows for better visualization and collection of specimens from smaller bronchi (Figures 18-2 and 18-3). The adult bronchoscopy tube is about 5- to 6-mm outer diameter (OD), and the pediatric tube is about 3-mm OD. The small diameter and ability to guide the catheter allow the operator to look into the bronchus to each lung segment (segmental bronchi). The fiberoptic bronchoscope is preferred over the rigid one when the patient is being mechanically ventilated or has disease or trauma to the skull, jaw, or cervical spine. As shown in Figure 18-2, a photo connection allows the assistant either to take still photographs of pulmonary anatomy or to videotape the entire procedure.

Figure 18-2 A flexible fiberoptic bronchoscope with its components and special features.

(From Wilkins RL, Stoller JK, Kacmarek RM: Egan’s fundamentals of respiratory care, ed 9, St Louis, 2009, Mosby.)

Figure 18-3 A flexible fiberoptic bronchoscopy procedure being performed on a patient.

(From Williams SF, Thompson JM: Respiratory disorders, St Louis, 1990, Mosby.)

A limitation of the pediatric unit is that there is no channel outlet for suctioning purposes. This is because of its small size. If a patient has an obstructing bronchial tumor, a special laser fiberoptic bronchoscope is used to burn part of the tumor. This enables the patient to breathe more easily, but this procedure is not a cure for the cancer.

2. Put the equipment together and make sure that it works properly

The fiberoptic bronchoscope is preassembled (see Figure 18-2 for its primary features). If photographing or videotaping is planned, the camera must be attached at the photo connection. Have a central or portable suctioning system set up with suction tubing. In addition, the following steps must be used to check for proper functioning:

1. Make sure the light source shines through to the distal end of the bronchoscope.

2. Look through the eyepiece. Point the distal end of the bronchoscope at a close object, and adjust the lens to bring it into focus.

3. Adjust the thumb control to bend the distal tip.

4. Pass biopsy forceps or brush through the channel port to the outlet.

5. Make sure the suction tubing connects to the channel port.

3. Troubleshoot any problems with the equipment

If the light source does not work, you must check the manufacturer’s equipment manual to help determine if the problem could be something simple such as a burned-out light bulb or a more serious problem. Similarly, problems with the camera equipment can be resolved by checking the manufacturer’s equipment manual.

Failure to pass a biopsy forceps or brush through the channel port probably means that an obstruction such as dried blood or tissue is present. Try applying suction through the channel port to clear out the debris. It also may be helpful to squirt sterile distilled water from a syringe through the channel. Try suctioning again or pushing the biopsy forceps through the channel. If alternating suction, instilling water, and pushing the forceps through the channel does not dislodge the debris, the unit cannot be used. Try soaking the bronchoscope in water to soften the debris before repeating these processes. If the channel cannot be cleared, the unit must be sent back to the manufacturer for repairs.

6. Thoracentesis

b. Assist with a thoracentesis procedure (Code: IIIJ3) [Difficulty: ELE: R, Ap; WRE: An]

The respiratory therapist may be responsible for preparing the patient, disinfecting the puncture site, setting up the sterile field, and preparing the equipment and supplies. Each hospital or physician may have a prescribed way of doing this. If the patient had a previous thoracentesis procedure, review the patient’s chart for information on the nature of the removed fluid. Be prepared to compare the previously removed fluid with the fluid being removed at this time. The general steps listed here apply to a thoracentesis procedure and a percutaneous needle biopsy of the pleura and lung (described below):

1. Inform the patient of the procedure. Have him or her sign the medical release form if not already done.

2. Have a sedative or pain-relieving agent administered if needed.

3. Position the patient sitting on the side of the bed and leaning on the overbed table as shown in Figure 18-4. Alternatively, the patient may straddle a chair and rest his or her arms and head on the back of the chair. The patient who cannot sit up is positioned on his or her side with the unaffected lung down on the bed.

4. If necessary, shave the insertion site clear of body hair.

5. Put on a sterile mask, cap, gown, and gloves according to protocol.

6. Disinfect the insertion site with a Betadine (iodine) soaked sterile 4 × 4 inch gauze pad. Place the pad at the center of the insertion site, and move it in a widening spiral away from the center. This step should be repeated with a second gauze pad. Let the Betadine dry.

7. Protect around the insertion site with a sterile fenestrated surgical drape.

8. Prepare the sterile field with needed supplies such as 1% Xylocaine and a variety of needles and syringes. Note: A Curity Thoracentesis Tray or other prepackaged tray will contain the supplies that will most commonly be used.

9. Assist the physician into his or her sterile mask, cap, gown, and gloves.

10. Assist the physician with the procedure as described in the following steps.

11. Make any adjustments in the patient’s respiratory care equipment as needed.

12. Dispose of any used supplies and so forth after the procedure is completed.

13. Tend to the patient’s comfort.

Figure 18-4 Technique for thoracentesis. The patient sits up and leans on the overbed table. The pleural fluid is withdrawn through the needle by the syringe and then directed into the collection jar.

General steps in the removal of pleural fluid:

1. Check the patient’s chest x-ray for the location of the pleural fluid (or targeted tissue for a needle biopsy) and its relationship to the ribs and other tissues.

2. Inform the patient not to move or cough during the procedure so that accidental needle damage to the pleura or lung can be avoided.

3. The physician will anesthetize the thoracentesis site as shown in Figure 18-5, A and B.

4. The physician will insert a large-gauge needle (often 16 gauge) with attached 50-mL syringe into the pleural fluid (see Figure 18-5, C). (A cutting needle is used during a needle aspiration of pleural or lung tissue.)

5. The sample is then aspirated. If there is more than 50 mL of pleural fluid, the two-way valve or three-way stopcock, rubber hose, and collection tube are assembled to remove the fluid (see Figure 18-4).

6. The needle is removed and a bandage is placed over the puncture site.

7. Place the patient with the unaffected side down on the bed for 1 hour.

8. Observe the patient for dizziness and cyanosis. Frequently check the patient’s pulse oximeter valve. Assess the patient’s vital signs according to hospital policy. Auscultate frequently for diminished breath sounds over the affected lung as a sign of pneumothorax. The physician should order a chest x-ray to check for pneumothorax. (See Box 18-3 for the commonly seen complications of a thoracentesis or needle biopsy.)

9. Evaluate the gross appearance of the fluid that has been removed. A transudate is found when the fluid is clear, serous, or light yellow. It contains few cells of any kind. This is most commonly found in patients with congestive heart failure and pulmonary edema. A chylothorax is found when the fluid is opalescent or pearly white in color. Chyle is lymphatic fluid that drains into the pleural cavity when the thoracic duct is blocked. This could be caused by injury to the neck or a tumor that invades the thoracic duct. A hemothorax is found when the pleural fluid is bloody (sanguineous or serosanguineous). Chest wall injury or puncture is the usual cause. An empyema is found when the fluid is thick and puslike with a foul odor. The patient usually has a bacterial infection of the lung and/or pleura, and infected fluid has entered the pleural space. In all cases, the collected pleural fluid sample should be sent to the laboratory for detailed analysis.

10. Send the collected sample to the laboratory for analysis.

Figure 18-5 Anesthetizing the needle insertion site and performing a thoracentesis. A, A 25-gauge needle is used to inject Xylocaine into the thoracentesis puncture site until the skin is raised. B, A 22-gauge needle is used to inject Xylocaine into the periosteum of the rib and surrounding tissues. The properly anesthetized patient should feel no pain during the thoracentesis. C, A 22- or larger-gauge aspirating needle is pushed through the numbed tissues, over the top edge of the rib, and into the pleural space. The fluid sample can now be aspirated.

(From Martin L: Pulmonary physiology in clinical practice: the essentials for patient care and evaluation, St Louis, 1987, Mosby.)

BOX 18-3 Common Complications of Thoracentesis

Infection

Hemothorax

Subcutaneous emphysema

Air embolism

Pneumothorax

Sudden mediastinal shift from removal of a large amount of pleural fluid (usually greater than 1500 mL in an adult)

Unstable vital signs from the sudden mediastinal shift

Pulmonary edema from the sudden reexpansion of the lung and mediastinal shift

7. Management of a pneumothorax

b. Assist with chest tube insertion (Code: III J5) [Difficulty: ELE: R, Ap; WRE: An]

A chest tube (also called tube thoracostomy) may be inserted into either one or both pleural spaces around the lungs, the mediastinal space, or the pericardial space around the heart. This procedure is indicated when air or fluid, or both, in any of these spaces interferes with normal lung or heart function. Box 18-4 lists the indications for the insertion of a chest tube.

BOX 18-4 Indications for the Insertion of a Chest Tube

PLEURAL SPACE (SEE Figure 18-6, D)

Tension pneumothorax

Greater than a 10% to 20% simple pneumothorax

Hemothorax

Empyema

Pleural effusion

Chylothorax

MEDIASTINAL SPACE

Free air

Free blood or other fluid

PERICARDIAL SPACE (SEE Figure 18-7)

Cardiac tamponade

Pneumopericardium

In addition to chest tube insertion, the patient is often given 100% oxygen by a nonrebreather mask for two reasons. The first is to treat the patient for hypoxemia. Second, if pure oxygen enters the pleural space through a tear in lung tissue, it will be quickly absorbed into the blood. This allows the lung to expand faster than if the patient was breathing a lower percentage of oxygen.

General steps in inserting a pleural chest tube follow:

1. Check the patient’s chest radiograph for the location of the air or fluid in the pleural space and its relation to the ribs and other tissues.

2. Prepare the patient as described in the thoracentesis procedure. The patient is usually positioned to lie on his or her back or with the lung of the unaffected side down on the bed.

3. The physician anesthetizes the tube insertion site as shown in Figure 18-5, A and B.

4. The physician creates an opening into the patient’s chest wall to place the chest tube (Figure 18-6). A tube to remove air is placed into one of two places and then advanced toward the apex of the lung. With a midclavicular approach, the tube is placed over the top edge of a rib into the second to fourth intercostal space. With a midaxillary approach (preferred site), the tube is placed over the top edge of a rib into the fourth to sixth intercostal space. A tube to remove fluid is placed over the top edge of the rib into the sixth to eighth intercostal space. It is inserted at the midaxillary line and advanced toward the posterior base of the lung. Mediastinal or pericardial tubes are placed via an opening below the xiphoid process and positioned posterior to the heart (Figure 18-7). This is most commonly done during open heart surgery.

5. The tube is secured by sutures and covered with a sterile 4 × 4 inch gauze pad and tape.

6. The other end of the tube is connected to the drainage system (discussed later).

7. Place the patient with his or her back against the bed or with the unaffected side down on the bed. The physician may want the head of the bed elevated or flat.

8. Observe the patient for dizziness, cyanosis, and changes in heart rate and respiratory rate. (See Box 18-4 for the most commonly seen complications.)

Figure 18-6 Technique for inserting a pleural chest tube. A, Anatomic landmarks. B, Dissecting through the tissues with a hemostat. C, Using a finger to widen the opening and ensure that the lung has not been punctured. D, Proper tube placement. Air is removed by a tube that is placed toward the apex of the lung. Fluid is removed by a tube placed toward the posterior base of the lung.

Figure 18-7 Pericardiocentesis procedure.

(From Black JM, Hawks JH: Medical-surgical nursing, clinical management for positive outcomes, ed 8, St Louis, 2009, Saunders.)

Exam Hint 18-3 (ELE, WRE)

Every past examination has included at least one question that relates to identifying a patient having a tension pneumothorax, requiring the insertion of a large-bore needle or a pleural chest tube. Know the indications of a tension pneumothorax, including sudden deterioration of vital signs and hypoxemia, decreased breath sounds over the affected lung, decreased chest wall movement over the affected lung, hyperresonant percussion noted over the affected lung, and shift of the mediastinal structures away from the affected lung. See Figure 1-2 for a chest radiograph showing a pneumothorax.

c. Manipulate a pleural drainage system by order or protocol (ELE code: IIA21) [ELE difficulty: R, Ap, An]

1. Select a pleural drainage system

Modern drainage systems consist of either three or four chambers or sections designed to regulate the vacuum level, hold any drained fluids, prevent any outside air from entering the patient’s thorax, and act as a pressure-relief valve in case the vacuum regulator should fail. Argyle and Pleur-evac are two well-known manufacturers. The systems for draining the pleural space are discussed here, but the principles are the same for draining the mediastinal and pericardial spaces.

2. Assemble a pleural drainage system, ensure that it works properly, and identify any problems with it

Refer to Figure 18-8 for the assembly and operation of the three-chamber drainage system. The four-chamber drainage system is shown in Figure 18-9 and is discussed concurrently.

Figure 18-8 Three-chamber pleural drainage systems. A, Homemade three-chamber drainage system. The depth that the suction column tube is placed under water determines the level of vacuum that will be applied against the patient’s pleural space. B, Schematic drawing of a modern manufactured three-chamber drainage system.

(From Shapiro BA, Kacmarek RM, Cane RD et al: Clinical application of respiratory care, ed 4, St Louis, 1991, Mosby-Year Book. Used by permission.)

Figure 18-9 Four-chamber pleural drainage systems. Top, Homemade four-chamber drainage system. The depth that the suction column tube in chamber C is placed under water determines the level of vacuum that will be applied against the patient’s pleural space. Bottom, Schematic drawing of a modern manufactured four-chamber drainage system. The fourth chamber acts to vent high-pressure air if the vacuum should be turned off or malfunction.

(Modified from Pilbeam SP, Deshpande VM: Chest tubes and pleural drainage, Curr Rev Respir Ther 5:151, 1983. Used by permission.)

a. Vacuum level.

The operation of the wall or central vacuum systems was discussed in Chapter 13. It is common practice to set a partial vacuum of −15 to −20 cm H₂O pressure to the pleural space.

b. Suction control.

The suction control chamber is dry when the unit is unpacked. Follow the manufacturer’s instructions for adding the correct amount of water. The proper water level is generally 15 to 20 cm high and results in that level of vacuum being applied to the patient’s pleural space.

It is normal to have room air drawn into the opening on top and bubbling through the water column. This corresponds to bottle or chamber C in Figure 18-9. The constant air bubbling causes the water level to gradually decrease from evaporation. Water must be added occasionally.

c. Water seal.

The water-seal chamber, which corresponds to chamber B in Figure 18-9

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