M5: Chest Tubes, Airways, and Respiratory Procedures

inhalation

diaphragm contracts, chest expands, negative P pulls air IN

exhalation

diaphragm relaxes, P pushes air OUT

abnormal lung sound examples

rhonchi (mucus in large airways), rales (fluid in alveoli), wheezes (narrowed airways), stridor (upper airway obstruction), pleural rub (inflamed pleura)

normal respiratory rates

adults → 12-20 breaths/min
children → 14-22 breaths/min

infants (<12mo.) → 30-60 breaths/min

What controls breathing?

medulla and pons sense CO2 (NOT O2)
high CO2 → fast, deep breathing
low CO2 → slow, shallow breathing
(CO2 drives breathing; rising CO2 lowers pH signaling brain to breathe faster)

external respiration

at the alveoli and pulmonary capillaries
O2 moves into blood, CO2 moves out of blood

internal respiration

at the systemic capillaries and body tissues
O2 moves into cells, CO2 moves from cells to blood

ventilation vs. respiration

ventilation → mechanics of breathing (airway, lungs)
respiration → gas exchange (alveoli, cells)

good ventilation, poor respiration → fluid in lungs
good respiration, poor ventilation → hypoventilation

perfusion

blood flow

pulmonary arteries carry blood to the lungs, veins return it to the heart, O2 binds Hb at alveolar-capillary membrane

hypoxia

low tissue oxygen

caused by poor ventilation/perfusion (V/Q mismatch)

pulmonary embolism

clot blocks lung blood flow, medical emergency

s/s → sudden dyspnea, chest pain, tachycardia, coughing blood, anxiety, “impending doom”

diagnosis → CTPA, D-dimer, V/Q scan, DVT u/s

treatment → anticoagulants, thrombolytics, IVC filter, O2, pain control

complications → lung tissue death, pulmonary HTN, cardiac arrest

goal of chest tube

remove air, blood, or fluid and restore negative pressure

chest tube indications

pneumothorax (air in pleural space collapses part/all of lung)
hemothorax (blood in pleural space from trauma/surgery)
pleural effusion/empyema (fluid/pus compresses lung and limits expansion)
after thoracic surgery (drains air/blood and restores pleural pressure)

3 chambers in a chest tube

collection chamber, water seal chamber, suction control chamber

collection chamber

function → collects drainage from pleural space
watch for → mark date/time/level each shift, sudden bright red surge means hemorrhage, notify MD if >100-200 mL/hr or bloody drainage

water seal chamber

function → 1-way valve that keeps air from re-entering the chest
watch for → tidaling w/ breathing is normal, continuous bubbling means air leak

suction control chamber

function → regulates the suction applied, often ~-20cm H2O per order, prevents excess suction on pleural cavity
watch for → gentle, steady bubbling is expected in a wet system

wet suction

• water level in suction chamber sets suction (ex: 20cm)

• gentle bubbling shows suction is working

• check water level → evaporation can lower it

dry suction

• dial sets suction level

• no bubbling in suction chamber → indicator shows suction is on

• quieter and easier to set up

things to keep at bedside for chest tube patient

vaseline gauze (Xeroform), occlusive dressing, new drainage system, sterile water

initial chest tube setup at bedside

1. hand hygiene, verify order (suction or water seal)

2. fill water seal to 2cm w/ sterile water

3. connect tubing securely, keep unit below chest

4. set dial (ex: -20) then raise wall suction until indicator shows

5. check tubing, apply occlusive dressing, assess tidaling

assessing a patient with a chest tube

respiratory status → rate/effort, SpO2, breath sounds, tracheal position, pain
drainage → amount, color, consistency, mark level and time each shift
tube/system → taped connections, no kinks or dependent loops, unit upright and below chest
site/skin → dressing dry/intact, check for crepitus (subcutaneous emphysema)

chest tube nursing considerations

• collection chamber upright, below insertion site

• tape to floor so it can’t tip

• mark level per order, DO NOT EMPTY

• report drainage >100mL/hr

• note drainage → purulent vs. bright red

• water seal tidals w/ breathing, continuous bubbling = air leak

• suction set to -20mmHg

• NEVER CLAMP A CHEST TUBE W/O MD ORDER

common chest tube problems

continuous bubbling in water seal → check connections/tubing for leak, assess pt, notify provider if persists
tubing disconnected → reconnect promptly using aseptic technique, assess pt
unit cracked or tipped over → set it upright or replace it, assess breathing
tube pulled out of the chest → cover site w/ sterile occlusive dressing per policy, call for help, assess for distress
no tidaling → check for kinks/loops/clots, may mean the lung has re-expanded, assess and report

potential chest tube complications

tension pneumothorax

signs → sudden dyspnea, tracheal deviation away from affected side, absent breath sounds, HOTN
actions → call for help, give oxygen, keep tube unclamped, prepare for decompression

hemorrhage

signs → sudden bright red surge or over 100 mL/hr, tachycardia, HOTN
actions → notify provider now, check v/s, secure IV access, prepare for volume

when to call provider emergently

sudden increase in drainage (>150-200mL/hr, bright red, clots), respiratory distress (tracheal deviation, hypoxia, spreading subcutaneous emphysema), continuous air leak (w/ no clear cause), device failure (or accidental tube removal)

assisting with chest tube removal

premedicate for pain, pt exhales or does the Valsalva maneuver as the tube is pulled, apply an airtight occlusive dressing, chest X-ray if warranted, watch for respiratory distress

chest tube removal preparation

1. verify order, lung re-expanded, minimal drainage, no air leak

2. explain the procedure in age-appropriate terms

3. premedicate 30-60min before

4. gather supplies → petroleum gauze, tape, sterile gloves, PPE

5. position semi/high Fowler’s

6. baseline → RR, SpO2, lung sounds, HR, pain, drainage

monitoring after a chest tube removal

assess breathing → q15-30min for 1-2hr, RR, effort, sounds, SpO2, pain
inspect dressing → drainage, bleeding, air leak
watch for pneumothorax → decreased breath sounds, tachypnea, cyanosis
chest x-ray → if ordered
deep breathing, coughing, IS use q2h
document → time, tolerance, dressing, findings, notifications

oropharyngeal airway

aka OPA, unconscious clients only (no gag reflex), size measured corner of mouth to angle of jaw (4-12cm), remove when gag reflex returns, watch for lip/tooth/tongue trauma

nasopharyngeal airway

aka NPA, conscious/semiconscious clients, size measured nose tip to earlobe (5-9cm), lubricate first, avoid w/ facial trauma or skull fracture, alternate nares q8-24hrs

endotracheal tube care

confirm placement (capnography, X-ray, breath sounds), secure tube, document cm mark at lip, cuff pressure 20-30 cm H2O checked q8-12hrs, oral care q2-4hrs, HOB elevated to prevent VAP, suction only as needed w/ sterile technique

**watch for unplanned extubation, obstruction, and right mainstem intubation

tracheostomy

surgical opening through the skin into the trachea in which a tracheal tube is inserted to keep the airway/trachea open, ensures O2/CO2 exchange

tracheostomy indications

prolonged mechanical ventilation, upper airway obstruction, inability to clear secretions, airway trauma/surgery, neuromuscular failure

parts of a tracheostomy tube

outer cannula → stays in the trachea
inner cannula → removed for cleaning or replaced
obturator → guides insertion of tube, KEPT AT BEDSIDE
cuff (if cuffed) → seals the airway, 20-30cm H2O

tracheostomy ties/dressings

ties sung → one finger fits underneath
two people change the ties
new trach → sterile gauze, kept dry and intact
cotton fibers can be aspirated or irritate the stoma so LINT-FREE DRESSINGS ONLY
monitor skin for breakdown/infection

tracheostomy nursing care

inner cannula → clean/replace at least q8-12hrs w/ sterile technique
stoma → clean/re-dress daily or when soiled, watch for infection/bleeding
ties → snug w/ one finger underneath, two people for ties change
cuff → keep 20-30cm H2O, check q8-12hrs
humidification → humidified oxygen or trach collar to thin secretions
swallow/speech → assess swallowing, involve speech therapy and communication aids

tracheostomy suctioning technique

1. prepare → sterile kit, suction at 100-150mmHg, catheter no more than half the tube diameter

2. preoxygenate → give oxygen before and between passes

3. insert → advance catheter w/o applying suction

4. withdraw → intermittent suction while withdrawing, 10s at most

5. reassess → SpO2, HR, breath sounds, rest before repeating

*STOP/REASSESS if SpO2 falls, HR drops or rhythm changes, client is in distress, 10 second limit is reached, suction only when needed not on a schedule

airway suctioning considerations

pre/post assessment, correct catheter size, pre-test suction, hyperoxygenate, maximum of 2 passes 10 seconds per pass w/ 30sec-1min between passes

what to keep at bedside in tracheostomy patient

obturator, suction equipment, oxygen, manual ventilation bag, spare trach tubes (1 same size, 1 size smaller)

mucus plug/obstruction

signs → catheter will not pass, rising work of breathing, falling SpO2
actions → remove/replace the inner cannula, suction and give oxygen, call for help early

accidental decannulation

signs → tube out/displaced, distress, air movement at the stoma
actions → call for help, stay with patient, give oxygen to face and stoma, reinsert w/ obturator only if trained

trach complications and responses

before/after bronchoscopy

before → confirm consent, NPO per policy (often 6-8hrs), baseline v/s and breath sounds, review anticoagulants/allergies, explain what to expect

after → NPO until gag reflex returns, HOB elevated, monitor v/s and respiratory effort, mild sore throat and blood-tinged sputum are expected, REPORT bright red blood or increasing breathlessness

emergent findings after bronchoscopy

stridor/laryngospasm → high-pitched breath sounds or airway spasm
hemoptysis → coughing up bright red blood beyond streaks
pneumothorax → sudden chest pain, dyspnea, falling SpO2, decreased breath sounds
aspiration → coughing/choking w/ fluids

thoracentesis

needle removes pleural fluid to diagnose or relieve dyspnea

position → sitting upright, leaning forward over table
after → auscultate, check site, expect chest X-ray
monitor for pneumothorax and respiratory distress, document amount/character of fluid

thoracoscopy

scope passed through chest wall into pleural space

chest tube is often placed afterwards, monitor drainage/air leak/pain/infection, coach coughing/deep breathing/IS, report increased dyspnea or bleeding/fever

check insertion site, listen to patient’s lungs, check oxygen levels

A chest tube has continuous bubbling in the water seal chamber. What is your first action?

remove/clean/replace inner cannula, give patient oxygen if needed, call for help if low oxygen persists

A trach client’s SpO2 is falling and the suction catheter will not pass. What do you do?

gag reflex

A client one hour after bronchoscopy asks for water. What must you check first?