Chapter 19: Chest Tube Insertion and Monitoring

Chapter 19: Chest Tube Insertion and Monitoring

Purpose of Chest Tubes

• Drain air, blood, or fluid from the pleural space

• Reestablish negative intrapleural pressure (allows lung expansion)

• Promote lung re-expansion and restore normal intrathoracic pressure

Insertion Locations

• Emergency department

• Bedside

• Operating room via thoracotomy incision

Indications for Removal

• Lung has fully re-expanded

• No further drainage into the pleural space

Key Nursing Concepts

• Loss of negative pressure causes lung collapse (pneumothorax)

• Restoring negative pressure allows alveoli to reopen and improve gas exchange

• Ongoing drainage indicates continued pleural pathology (air leak, bleeding, effusion)

Chest Tube Systems

Most commonly uses a disposable three-chamber drainage system

Three Chambers

• Drainage Collection Chamber

  • Collects air, blood, or fluid from the pleural space

• Water Seal Chamber

  • Acts as a one-way valve

  • Allows air to exit pleural space during exhalation

  • Prevents air from entering lungs during inhalation

• Suction Control Chamber

  • Regulates amount of suction applied

  • May be wet or dry

Water Seal Chamber

• Sterile fluid added to the 2 cm line minimum (follow manufacturer guidelines)

• Must remain upright and below chest insertion site

• Monitor water level routinely (evaporation risk)

• Add sterile fluid as needed to maintain prescribed level

Wet Suction Control

• Amount of suction determined by height of sterile fluid in chamber

• Common prescription: −20 cm H₂O

• Connected to wall suction

• Adjust until gentle bubbling is present (excess bubbling increases evaporation)

Dry Suction Control

• Provider sets suction level on device (typically −20 cm H₂O)

• When connected to wall suction, regulator is set per manufacturer instructions

Tidaling (Normal Finding)

• Spontaneous breathing

  • Fluid rises with inspiration

  • Fluid falls with expiration

• Positive-pressure mechanical ventilation

  • Fluid rises with expiration

  • Fluid falls with inspiration

Abnormal Findings

• Cessation of tidaling

  • Lung re-expansion or system obstruction

• Continuous bubbling in water seal

  • Indicates air leak in system

• Intermittent bubbling

  • Expected when removing air (exhalation, coughing, sneezing)

  • Absence of bubbling afterward indicates air removal complete

Mediastinal Chest Tubes

• Used after open-heart surgery

• Bubbling and tidaling not expected

• Fluid level may show cardiac pulsations

Chest Tube Insertion

Indications

• Removal of air, blood, fluid, or pus from pleural or mediastinal space

• Restore lung expansion and cardiopulmonary stability

Potential Diagnoses

• Pneumothorax

  • Air in pleural space causing partial to complete lung collapse

• Hemothorax

  • Blood in pleural space causing lung collapse

• Postoperative Chest Drainage

  • Thoracotomy or open-heart surgery

• Pleural Effusion

  • Fluid accumulation in pleural space

• Pulmonary Empyema

  • Pus in pleural space due to infection, lung abscess, or infected effusion

Client Presentation

• Dyspnea (impaired gas exchange)

• Distended neck veins (possible increased intrathoracic pressure)

• Hemodynamic instability

• Pleuritic chest pain

• Cough

• Absent or diminished breath sounds on affected side

• Hyperresonance to percussion (pneumothorax)

• Dullness or flatness to percussion (hemothorax, pleural effusion)

• Asymmetrical chest wall movement

Chest Tube Insertion Consideration

Preprocedure

• Verify informed consent is signed

• Explain procedure and expected improvement in breathing (reduces anxiety, promotes cooperation)

• Assess for allergies to local anesthetics

• Position client supine or semi-Fowler’s

• Prepare chest drainage system per facility protocol

  • Fill water seal chamber to prescribed level

• Administer prescribed analgesia and sedation

• Prep insertion site with povidone-iodine or approved antiseptic

Intraprocedure

• Tube placement depends on indication

  • Fluid drainage: tip near lung base

  • Air removal: tip near lung apex

• Assist provider with insertion, dressing application, and drainage system setup

• Place drainage system below chest level

• Keep tubing straight and unobstructed to promote gravity drainage

• Continuously monitor vital signs and client response

Postprocedure

• Assess at least every 4 hr

  • Vital signs

  • Breath sounds

  • SpO₂

  • Skin color

  • Respiratory effort

• Encourage coughing and deep breathing every 2 hr

• Keep drainage system below chest level at all times, including ambulation

• Monitor chest tube placement and function

  • Check water seal level every 2 hr and refill as needed

  • Expect tidaling with respirations

  • Document drainage amount and color

    • Hourly for first 24 hr

    • At least every 8 hr after

    • Mark date, time, and level on container each shift

    • Report drainage >70 mL/hr, sudden increases, cloudy, or red drainage

  • Monitor suction control chamber and maintain prescribed level

  • Verify dry suction regulator setting if applicable

  • Ensure no dependent loops, kinks, occlusions, or loose connections

  • Continuous bubbling only in suction chamber, not water seal

• Monitor insertion site

  • Redness

  • Pain

  • Signs of infection

  • Crepitus (subcutaneous emphysema)

• Tape all connections securely

• Position semi-Fowler’s to promote lung expansion

• Administer pain medication as prescribed

• Obtain chest x-ray to confirm placement

• Keep two hemostats, sterile water, and occlusive dressing at bedside

• Clamp chest tube only if prescribed

  • Risk of tension pneumothorax if clamped improperly

• Do not milk, strip, or clamp tubing unless prescribed

  • Excessive negative pressure can damage lung tissue

• Notify provider immediately if

  • SpO₂ < 90%

  • Chest tube eyelets become visible

  • Drainage stops or exceeds prescribed amount in first 24 hr

  • Complications occur

Chest Tube Removal

• Administer pain medication 30 min before removal

• Assist provider with sutures and removal

• Instruct client to

  • Exhale and bear down (Valsalva maneuver)

  • Or take a deep breath and hold

  • (Increases intrathoracic pressure, prevents air entry)

• Apply airtight sterile petrolatum gauze dressing

  • Secure with heavy tape

• Obtain follow-up chest x-ray as prescribed

• Monitor for

  • Excessive drainage

  • Infection

  • Recurrent pneumothorax

Chest Tube Insertion Complication

Air Leaks

• Often caused by unsecured connections

Nursing Actions

• Monitor water seal chamber for continuous bubbling

• Check and tighten all connections

• Notify provider if air leak persists

• If prescribed, briefly clamp tubing with padded clamp to locate leak

  • Remove clamp immediately after assessment

Accidental Disconnection, System Breakage, or Removal

• Medical emergency requiring immediate provider or rapid response notification

Nursing Actions

• If tubing disconnects

  • Instruct client to exhale and cough

• If drainage system is damaged

  • Submerge chest tube end in sterile water to reestablish water seal

• If chest tube is removed

  • Cover site with dry sterile gauze and occlusive dressing

Tension Pneumothorax

• Causes

  • Sucking chest wound

  • Prolonged clamping

  • Kinked or obstructed tubing

  • High PEEP mechanical ventilation

• Assessment findings

  • Tracheal deviation

  • Absent breath sounds on one side

  • Distended neck veins

  • Severe respiratory distress

  • Chest asymmetry

  • Cyanosis

• Notify provider or rapid response team immediately

A nurse is caring for a client who has a chest tube and drainage system in place. The nurse observes that the chest tube was accidentally removed. In what order should the nurse perform the following actions?

1

Assess respiratory status.

2

Obtain a chest x-ray.

3

Apply sterile gauze to the insertion site..

4

Place tape around the insertion site.

When prioritizing hypothesis, the nurse should identify the greatest risk to the client is injury from air entering the pleural space and causing the development of a tension pneumothorax.

Application of a sterile gauze to the site is the first action the nurse should take. This prevents air from entering the pleural space and reduces the risk for development of a tension pneumothorax.

The nurse should, next, place tape around the insertion site to ensure the sterile gauze remains intact.

Next, the nurse should assess the client’s respiratory status for indications of respiratory distress.

After assessing the client, nurse should obtain a chest x-ray to determine if the lung is inflated or if the client has a pneumothorax after the chest tube was accidentally removed.

---

1

Apply sterile gauze to the insertion site.

2

Place tape around the insertion site.

3

Assess respiratory status.

4

Obtain a chest x-ray.

A nurse is assessing a client who has a chest tube and drainage system in place. Which of the following are expected findings?

Select all that apply.

a

Continuous bubbling in the water seal chamber

b

Gentle constant bubbling in the suction control chamber

c

Rise and fall in the level of water in the water seal chamber with inspiration and expiration

d

Exposed sutures without dressing

e

Drainage system upright at chest level

b Gentle constant bubbling in the suction control chamber

c Rise and fall in the level of water in the water seal chamber with inspiration and expiration

A nurse is assisting a provider with the removal of a chest tube. Which of the following actions should the nurse take?

a

Instruct the client to lie prone with arms by the sides.

b

Complete a surgical checklist on the client.

c

Remind the client that there is minimal discomfort during the removal process.

d

Place an occlusive dressing over the site once the tube is removed.

d

Place an occlusive dressing over the site once the tube is removed.