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vent, patients have protection from accumulating highnegative pressure.Vacuum indicatorWhen vacuumis present inthe collectionchamber, asymbol willremain visibleVacuum is present Vacuum is not presentin the vacuumindicatorwindow. When vacuum is not present (atmosphericpressure) no symbol will appear. All patient tubeconnections and the vacuum indicator window shouldbe checked regularly for vacuum confirmation.Automatic high negativity reliefDuring prolonged episodes of extreme negativepressure (as with chest tube stripping), Maquet’scontrolled release system will automatically relieveexcessive high negative pressure to a lower level(release set at approximately -50 cmH2O).System disconnection and optionsfor autotransfusionAll models are equippedwith in-line connectors.Maquet offers flexibilityfor prescribing post-opautotransfusion at anytime. These locking patienttube connectors providefor disconnection after useor rapid in-line ATS bloodbag attachment, whenrequired.11

Maquet product feature est draindesignEasy to store,handle, andtransport. Lesspackaging.Environmentally responsible.Less waste is more costsavings for the hospital.Adjustabledry suctioncontrolContinuallyand automatically adjuststo changes inpatient air leaksand/or fluctuations in hospitalwall suction.Regulator dial can be setto any desired suctionpressure between -10 cmH2Oand -40 cmH2O. Providesaccurate, reliable suctioncontrol for a wide range ofchest drainage applications.SuctionmonitorbellowsEasy confirmation of suctionoperation.Large, bright colored bellowsexpands across suction monitor window whensuction is operating.*PrepackagedwaterOnly the air leakmonitor needsto be filled.No more overfilled orunderfilled air leak monitors.The ultimate in time andcost savings.Blue tint airleak monitorEfficient air leakdetection.Air leak monitor turns bluewhen filled.Graduatedair leakmonitorFast, easydetection andmonitoringof patient airleaks.Air leak bubbling can rangefrom 1 (low) to 5 (high) formonitoring patient air leaktrends.Filteredmanual ventEasy-to-use tolower the watercolumnProvides effective manual ventcontrol when lowering height ofair leak monitor.HighnegativepressureprotectionAdvanced valveautomaticallyvents highvacuum.Valve design offers a controlledrelease during episodes ofprolonged high negativepressure (set at approximately-50 cmH2O).VacuumindicatorQuick and easyconfirmationof vacuumwhen presentin collectionchamber.symbol remainingvisible in the vacuumindicator window confirmsvacuum. No symbolindicates no vacuum.*patented12

mper resistantpositive pressurerelief valve automatically filter protection patient fromaccumulating positivepressure.Integral to the system,this valve automatically prevents tensionpneumothorax duringaccidental suction lineocclusion.Autotransfusion CapabilitiesMaquet providesnumerous options foremergency or postop autotransfusionon demand.Fast, convenient ATS baguse or continuous ATSvia infusion pump.In-lineconnectorSmooth, low-profiledesign has audiblelocking mechanism.Connector providessystem disconnectionor fast in-line ATS bagattachment.CollectionchambergraduationsImproved collectionchamber design iseasy to read.Large collection windowgraduations provide fastand accurate volumeassessment.Maximumknock-overprotectionDry seal offerspatient protection.Dry seal integrity ispreserved duringtransport andaccidental knock-over.Knock-overnozzlesAllows fluid volumesto be fully recoveredwhen drain is returned to the uprightposition.Reduces the incidenceof interchamber spills.Easy-to-griphandleComfortable designfacilitates hand-off.Makes patientambulation and patienttransport easy.FlexihangersAccommodatestoday’s newer beddesigns.Flexible hangers(located inside thehandle) allow drain to behung from a single point.Swing outfloor standSecure systemplacement during setup or on floor.Floor stand swings outfor maximum stability,closes for transport.NeedlelessaccesssamplingportIn-line fluid removal.No needle necessary.Connects to anystandard luer-locksyringe.13

System set upOpen packageRemove non-sterile outer protective bag. Maquet chestdrains are wrapped in CSR wrap and should be openedfollowing hospital approved sterile technique.Requirements for set up30 ml of water will be required. Follow hospital’s protocolfor type of water to be used. Sterile saline should be usedfor ATS applications.Four step set upSwing floor stand open for set up. For models equippedwith an in-line connector, move the patient tube clampcloser to the chest drain (next to the in-line connector)for set up convenience and patient safety. Follow steps1-4 and refer to each model’s operating instructions foradditional details concerning system set up, operation,indications for use, and warnings and cautions.14

Step 1Connect chest drain to patientRemove patient tube connector cap and insert steppedpatient connector into patient’s catheter(s). Remove orcut off stepped connector for “Y” connector insertion.If desired, use of nylon bands around catheter andpatient tube connections will assure an air-tightconnection. Connect chest drain to patient prior toinitiating suction.Indwelling chest tubeStep 2Connect chest drain to suctionAttach suction line to suction port on top of chest drain.Suction sourceThe suction source should provide a minimum vacuumpressure of -80 mmHg at 20 liters of air flow per minutefor chest drain operating efficiency at a suction controlsetting of -20 cmH2O. The suction source vacuumshould be greater than -80 mmHg when multiple chestdrains are connected to a single suction source.15

Step 3Turn suction source OnIncrease suction source vacuum to -80 mmHg orhigher. The suction monitor bellows must be expandedto the s mark or beyond for a -20 cmH2O or higherregulator setting. The regulator control dial, located onthe side of the drain, can be adjusted to any suctionsetting between -10 cmH2O and -40 cmH2O. Dial downto lower the suction setting and dial up to increase.Suction monitor bellowsWhen the suction control regulator is set at -20 cmH2Oor higher, the bellows must be expanded to the s markor beyond when suction is operating. If the bellows isobserved to be expanded, but less than the s mark,the suction source vacuum pressure must be increasedto -80 mmHg or higher. For a regulator setting lessthan -20 cmH2O suction (-10 cmH2O), any observedbellows expansion across the monitor window willconfirm suction operation. The bellows need not beexpanded to the s mark for pressures less than -20cmH2O, just visibly expanded to confirm suctionoperation.Turn suction source to -80 mmHg orhigher. Bellows must be expanded tos mark or beyond for -20 cmH2O orhigher regulator setting.16

Step 4Fill air leak monitorto fill lineFill air leak monitor to the fill line by syringe (no needle)with 30 ml of sterile water or sterile saline via theneedleless injection port located on the back of thedrain. For models available with sterile fluid, twist topoff syringe and insert tip into needleless luer port.Depress syringe plunger into luer port and squeezecontents into air leak monitor until fluid reaches fill line.H 2OOnce filled, water becomes tinted blue for visibilityof air leaks.17

What to check duringsystem operationVerifying suction operation via the suctionmonitor bellowsThe bellows locatedin the suction monitorwill expand only whensuction is operating.The monitor bellowswill not expand whensuction is not operatingor disconnected. Thecalibrated s mark allowsBellows must be expanded to sconfirmation of vacuummark or beyond for a -20 cmH2Ooperation over a wideor higher regulator setting.range of adjustable suctioncontrol settings.Increase vacuum source when bellows is notexpanded to s markIf the bellows is observed to be expanded, but lessthan the s mark, the vacuum source pressure must beincreased to -80 mmHg or higher.Not enoughvacuum for-20 cmH2O orhigher suctioncontrol setting.18Normal suctionoperation for-20 cmH2O orhigher.Increase suctionsource to -80 mmHgor higher.

Changing suction pressureChanging suction pressure is accomplished byadjusting the rotary dry suction control dial locatedon the side of the drain. Dial down to lower suctionpressure and dial up to increase suction pressure.NOTE: When changing suction pressure from a higherto lower level, use of the manual high negativity ventafter regulator adjustment will reduce excess vacuumdown to the lower prescribed level.Recording drainage volumeThe collection chamber incorporates a writing surfacewith easy-to-read fluid level graduations. Please referto individual product for specific graduation.Placement of unitFor optimum drainage results, always place chest drainbelow the level of the patient’s chest in an uprightposition. To avoid accidental knock-over, it isrecommended to swing the floor stand open for secureplacement on floor or to hang the system bedside withthe hangers provided.19

Verifying air leak monitor operationThe air leak monitor can be filled and maintained atthe fill line to ensure proper operation and should bechecked regularly when used for extended periods.As required, additional water may be added by syringevia the luer port located on the back. Fill to the fill line.Observing air leak monitor for patient air leaksAtrium Express chest drains offer air leak detectionwith rapid air leak assessment and improved visibilitydue to the tinted water. A patient air leak is confirmedwhen air bubbles are observed going from right to leftin the air leak monitor.Continuous bubbling in the bottom of the air leakmonitor will confirm a persistent air leak.Intermittent bubbling with float ball oscillation willconfirm the presence of an intermittent air leak.No bubbling with minimal float ball oscillation at thebottom of the air leak monitor will indicate no air leakis present.20

Vacuum indicatorWhen vacuum is present in the collection chamber,asymbol will remain visible in the vacuum indicatorwindow. When vacuum is not present (atmosphericpressure) no symbol will appear. All patient tubeconnections and the vacuum indicator window shouldbe checked regularly for vacuum confirmation.Graduated air leak monitorAir leak bubbling can range from 1 (low) to 5 (high).Air bubbles create an easy to follow air leak patternfor monitoring patient air leak trends.Sampling patient drainageSampling of patient drainage must be in accordancewith approved hospital infection control standards.Selected models include a needleless luer port on thepatient tube connector for sampling patient drainage.Alcohol swab the luer port prior to syringe attachment(no needle). Fluid samples can also be taken directlyfrom the patient tube by forming a temporarydependent loop and inserting a 20 gauge needle at anoblique angle. Alcohol swab the patient tube prior toinserting syringe at a shallow angle. Do not puncturepatient tube with an 18 gauge or larger needle.In-line patient tube connectorThe locking in-line patienttube connector providessystem replacement, simpledisconnection after use, andrapid in-line ATS blood bagattachment when required.The in-line connector mustremain securely connectedat all times during operation and patient connection.Do not separate in-line connector prior to clampingoff patient tube clamp.21

Positive pressure protectionMaquet’s positive pressurerelease valve, located on top ofdrain, opens instantly to releaseaccumulated positive pressure.Integral to the system, this valvedesign is tamper-resistant. Donot obstruct the positive pressure valve.Swing out floor standMaquet’s floor stand swings open for convenientsystem set up and secure placement on floor. It isrecommended that the floor stand be closed duringpatient transit or when unit is hung on bed.Multi-position hangersThe multi-position hangersare easily lifted from insidethe handle. Press hangersinto handle when not inuse. The flexible hangersallow the drain to be hungbedside from a single point.Lift tousePushin tolockManual high negativity ventTo manually lower theheight of the watercolumn or to lowerpatient pressure whenconnected to suction,temporarily depressthe filtered manual vent Do not use when suction is notoperating.located on top of thedrain until the watercolumn lowers to the desired level. Do not use manualvent to lower water column when suction is notoperating or when the patient is on gravity drainage.22

Patient tube clampThe removable patient tube slide clamp provided within-line connector models must remain open at all timesduring system operation. It is recommended to movethe patient tube clamp next to the in-line connector(closer to the chest drain) for set up convenience androutine visual check. Do not keep patient tube clampclosed when system is connected to patient. Tubeclamp must be closed prior to in-line connectorseparation.Move clampcloser to drain,next to in-lineconnectorCAUTION:Keep clampopen at alltimes whensystem isconnected topatientGravity drainageFor gravity drainage applications, the drain should beplaced below the patient’s chest in an upright position.Disconnect the suction source vacuum line from thesuction line port.System disconnectionFor models equipped with an in-line connector, closethe patient tube slide clamp prior to disconnectingthe chest drain patient tube from patient. Clamp offall indwelling thoracic catheters prior to disconnectingchest drain from patient.23

Anatomy and physiologyreviewAnatomy of the chestThe chest wall is composed of the ribs, sternum, andthoracic vertebrae and are all interlaced and covered withintercostal muscle to form a semi-rigid structure. Thelower boundary or floor of the thoracic cavity is known asthe diaphragm, which is also composed of muscle.Although the thoracic cavity contains two passagewayswhich are open to the outside environment, theesophagus and trachea, the cavity itself is an enclosedstructure. The interior of the thoracic cavity can bedivided into three distinct areas: the mediastinum andtwo separate chambers for each lung. The superiormediastinum consists of soft tissue which enclosesthe esophagus, trachea, heart, aorta, and other majorvessels. The mediastinum acts as a flexible partitionwhich extends from the front-to-back and top-tobottom of the central portion of the chest.The inside of the rib cage is lined by a membranecalled the parietal pleura while the lungs are coveredby another membrane called the pulmonary or visceralChest wallRightlung cavity24Left lungcavityDiaphragmMediastinalcavity

pleura. Under normal conditions, these two pleuralsurfaces slide against each other allowing the lungs toexpand and contract. These two surfaces are closelyheld to one another, being separated only by a verythin film of lubricating fluid secreted by the pleura,called pleural fluid.Why the lungs are expandedA principal factor which keeps the visceral and parietalpleurae together and not separating is vacuum,commonly referred to as negative pressure. Thisnegative pressure, or vacuum, is present during normalrespiration with the membranes closely intact undernormal conditions. The presence of negative pressurebetween these two membranes is what helps holdthe visceral pleura in close contact with the parietalpleura at all times. Hence, negative pressure or vacuumaround the outside of the elastic lung is what keepsthe lung in a fully expanded position, counteracting thelung’s normal tendency to shrink in size.ParietalpleuraPleuralspaceVisceralpleuraIf air, fluid, or blood were to enter the space betweenthese two membranes, the space created is known asa pleural space and is an abnormal occurrence. Whenthis occurs, the lungs can no longer fully expand witheach inspiration and intense pain results, inhibiting thevoluntary effort of breathing.25

The mechanics of breathingRespiration is the cycle of inspiration and expiration inwhich air moves in and out of the lungs due to changesin pressure. When the diaphragm is stimulated bythe phrenic nerve, it contracts and moves downward.With the help of the external intercostal muscles, therib cage moves up and out. The lung itself expandsbecause of the movement of the diaphragm and thechest wall. The surface tension of the pleural fluidtogether with the naturally occurring vacuum pressureinduced by the pulling action of the diaphragm is whatactually holds the pleural membranes together, thuskeeping the lungs fully expanded.Under normal conditions,there is always negativepressure in the pleuralcavity. The degree ofnegativity, however,changes duringrespiration. Duringnormal inspiration,intrapleural vacuumpressure is approximately -8 cmH2O,while during expirationthe vacuum pressurefalls to -4 cmH2O.With deep inspiration,intrapleural pressurescan be even morenegative.26Inspiration-8 cmH2OExpiration-4 cmH2O

Why dry seal chest drainsare usedClinical needs for chest tube drainageWhen the chest wall is opened either by surgery orchest injury, the in-rush of air causes the vacuum inthe patient’s pleural cavity to escape and atmosphericair to enter the intrapleural space. Since the normalnegative pressure or vacuum is no longer present, thelungs collapse as they depend upon this negativity orvacuum to stay fully expanded up against the insideof the chest wall. When air enters or becomes trappedinside the chest causing a pleural space, the lungscannot fully expand, and the patient will experiencedifficulty in breathing. This condition is known as apneumothorax. This is a frequent occurrence after allthoracic and cardiac surgeries, as well as with mostchest wall injuries. Often there is a combination of bothair and blood present in this abnormal space, causing asimilar effect on breathing. When blood collects in thepatient’s pleural space, it is known as a hemothoraxand when there is the combination of both blood andair, it is known as a hemopneumothorax.PneumothoraxHemopneumothorax27

Tension pneumothorax is a more serious complicationthat can develop when air continues to leak from ahole in the lung directly into the pleural space and hasno way to escape. As more and more

traditional water seal for one-way seal protection, the Express features a dry seal valve as its seal. This mechanical one-way valve allows air to escape from the chest and prevents air from going back to the chest. The advantage of a dry seal valve is it does not require water to operate and it is n