tube

Tube Malposition / Blockage

Cause: Kinking, dependent loops, clots, improper placement

Tube Malposition / Blockage

Sign: No tidaling

Tube Malposition / Blockage

Sign: Absent drainage

Tube Malposition / Blockage

Sign: Worsening dyspnea

Tube Malposition / Blockage

Sign: Absent breath sounds

Tube Malposition / Blockage

Management: Reposition patient; unkink tubing

Tube Malposition / Blockage

Management: Milk/squeeze gently ONLY if policy allows

Tube Malposition / Blockage

Management: Notify physician; order chest X-ray

Tube Malposition / Blockage

Management note: Routine milking/stripping is NOT recommended — risk of high negative pressure & tissue damage

Persistent Air Leak

Cause: Lung injury or a leak in the system itself

Persistent Air Leak

Sign: Continuous bubbling in the water-seal chamber

Persistent Air Leak

Management: Check and tighten/tape all connections; if the leak persists, notify the physician (possible bronchopleural fistula)

Accidental Disconnection

Cause: Tubing separates from the drainage system

Accidental Disconnection

Sign: Bubbling stops; risk of air entry into the chest

Accidental Disconnection

Management: Place the tube end in sterile water; reconnect using sterile technique; notify the provider

Accidental Tube Removal / Dislodgment

Cause: Tube pulls out of the insertion site

Accidental Tube Removal / Dislodgment

Sign: Open chest wound, sucking sound, respiratory distress

Accidental Tube Removal / Dislodgment

Management: Cover the site with a sterile occlusive dressing taped on 3 sides; provide oxygen; notify the physician urgently

Subcutaneous Emphysema

Cause: Air leaking into the surrounding soft tissue

Subcutaneous Emphysema

Sign: Swelling with a "crackling" (crepitus) sensation on palpation

Subcutaneous Emphysema

Management: Assess extent and airway; ensure the tube is not kinked; notify the physician

Rapid Recall — Unit 2 Exam Cues: No tidaling

No rise/fall of fluid in the tubing with respiration

Rapid Recall — Unit 2 Exam Cues: No tidaling

Think blockage, kink, or lung re-expansion

Rapid Recall — Unit 2 Exam Cues: No tidaling

Always check blockage, kink, or lung re-expansion in that order

Rapid Recall — Unit 2 Exam Cues: Continuous bubbling in the water-seal chamber

AIR LEAK

Rapid Recall — Unit 2 Exam Cues: Continuous bubbling in the water-seal chamber

Different from gentle bubbling in the SUCTION chamber, which is normal for wet suction

Rapid Recall — Unit 2 Exam Cues: Crepitus/crackling on palpation around the tube site

Subcutaneous emphysema

Rapid Recall — Unit 2 Exam Cues: Golden rule

NEVER clamp a chest tube that is bubbling/has an air leak unless specifically ordered

Rapid Recall — Unit 2 Exam Cues: Golden rule

Clamping can cause a tension pneumothorax

Pneumothorax

Air in the pleural space

Hemothorax

Blood in the pleural space

Pleural Effusion

Excess (usually serous) fluid in the pleural space

Empyema

Accumulation of infected fluid or pus in the pleural space

Chylothorax

Accumulation of chyle (a milky-white lymphatic fluid) in the pleural space

Chylothorax

Chyle contains fat (especially triglycerides)

Chylothorax

Chyle contains lymph

Chylothorax

Chyle contains proteins

Chylothorax

Chyle contains lymphocytes

Chylothorax

Chyle contains fat-soluble vitamins

"Milky-White" Drainage Fluid

Chylothorax (chyle), NOT infection

"Pus / Infected Fluid"

Empyema

Triangle of Safety

The most important landmark for chest tube insertion, located on the lateral chest wall

Triangle of Safety

Keeps the tube away from major vessels, nerves, and muscle

Triangle of Safety Posterior Border

Anterior border of the latissimus dorsi

Triangle of Safety Anterior Border

Lateral border of the pectoralis major

Triangle of Safety Inferior Border

Horizontal line at the level of the nipple (roughly the 5th intercostal space)

Triangle of Safety Apex

Below the axilla (base of the axilla)

Three-Bottle (or 3-Chamber) System

Most commonly used traditional setup

Three-Bottle (or 3-Chamber) System

Now built into a single modern disposable unit, but conceptually still 3 chambers

Three-Bottle (or 3-Chamber) System

Combines a fluid collection chamber, a one-way water-seal chamber, and a suction control chamber

Three-Bottle (or 3-Chamber) System

Safer and more effective than simpler systems when controlled suction is needed

Wet Suction Control

Suction regulation uses a water column

Wet Suction Control

Uses water for suction control: Yes

Wet Suction Control

Example setting is −20 cm H2O

Wet Suction Control

Bubbling in the suction-control chamber is usually gentle, continuous bubbling

Wet Suction Control

Requires a suction source when ordered: Yes

Wet Suction Control

Main nursing concern is maintaining the correct water level (evaporation changes the suction pressure)

Dry Suction Control

Suction regulation uses a mechanical regulator / dial

Dry Suction Control

Uses water for suction control: No

Dry Suction Control

Example setting is −20 cm H2O

Dry Suction Control

Bubbling in the suction-control chamber is usually not required

Dry Suction Control

Requires a suction source when ordered: Yes

Dry Suction Control

Main nursing concern is verifying the correct dial/indicator setting

Wet Suction (Rapid Recall)

Gentle continuous bubbling in the SUCTION chamber is expected and normal

Vigorous/Violent Bubbling in the Suction Chamber

Suction is turned up too high, not a good thing — turn down until gentle

Bubbling in the Water-Seal Chamber

Reflects an air leak, not suction strength

Tube Comes Out of the Patient (Accidental Removal)

First priority is to seal the insertion site to prevent air from entering the chest

Tube Comes Out of the Patient (Accidental Removal) Step 1

Ask the client to cough and exhale immediately

Tube Comes Out of the Patient (Accidental Removal) Step 2

Apply a sterile occlusive dressing (e.g., Vaseline/petroleum gauze)

Tube Comes Out of the Patient (Accidental Removal) Step 3

Tape on 3 sides only — allows air to escape, prevents air from entering, and reduces the risk of a tension pneumothorax

Tube Comes Out of the Patient (Accidental Removal) Step 4

Call the provider immediately

Tube Comes Out of the Patient (Accidental Removal) Step 5

Monitor closely for respiratory distress

Tube Disconnects From the Drainage System

First priority is to prevent air from being sucked back into the pleural space

Tube Disconnects From the Drainage System (Simple Disconnection)

Apply an antiseptic swab to the tubing ends and reconnect

Tube Disconnects From the Drainage System (Damaged Bottle/Unit)

Place the end of the chest tube into sterile water or saline (~2 cm depth) to create a temporary water seal, then notify the provider

3-Sides Tape Rule

Taping an occlusive dressing on 3 sides creates a one-way "flutter valve"

3-Sides Tape Rule

Air can still escape out the open side (prevents tension pneumothorax) but cannot be sucked back in

4-Sided Taping

Never tape all 4 sides over an open pneumothorax wound — this traps air in and can cause a tension pneumothorax

Tube Out of the Patient vs. System

Tube out of the PATIENT → cover the site

Tube Out of the Patient vs. System

Tube out of the SYSTEM → protect the open tubing end (sterile water)