Ch 19: Chest Tube Insertion & Monitoring

Chest Tube Insertion

• are inserted into the pleural space to drain fluid, blood, or air

  • re-establish a negative pressure

  • facilitate lung expansion

  • restore intrapleural pressre

• inserted in ER, bedside, OR through a thoracotomy incision

• removed: when lungs have re-expanded or there is no more fluid drainage into the pleural space

Negative pressure in the lungs?

to keep lungs inflated

Disposable three-chamber drainage system = most often used

• First Chamber: drainage collection

• Second Chamber: water seal

• Third Chamber: suction control (can be wet or dry)

First Chamber: drainage collection (suction control)

• bubble

• Continuous gentle bubbling

• Wet→sterile water added to {{792516996708778::20cm}} & connected to suction - add sterile water PRN

• Dry→below regulator is dialed to prescribed suction lbl & connected to wall suction

Second Chamber: water seal

• tidal

• Sterile water fluid level to 2cm - tidaling is expected

• Rise w/ inspiration (> negative pressure in lungs) & falls w. expiration

• Cessation of tidaling→signals ling re-expansion or obstruction in system

• Continuous bubbling→air leak

Third Chamber:

suction control (can be wet or dry)

Water Seals

• created by adding sterile fluid to a chamber up to 2 cm line

• allows air to exit from pleural space on exhalation & stops air from entering the lungs with inhalation

• to maintain: keep chamber upright & below the chest tube insertion site at all times

  • routinely monitor water level

• continuous bubbling = indicates air leak

  • intermittent bubbling is common during exhalation, sneezing, or coughing

  • no bubbling = air has been removed

Wet Suction

• height of sterile fluid in the suction control chamber determines the amount of suction transmitted to the pleural space

• level of water = suction pressure

• system is attached to a suction source

• commonly prescribed: -20 cm $H^2O$

Dry Suction

the provider prescribes a level of suction for the device (typically -20)

Tidaling

• movement of fluid level with respiration is expected

• spontaneous resp: fluid level will rise with inspiration (> in negative pressure in lung) & fall with expiration

• positive-pressure mechanical vent: fluid will rise with expiration & fall with inspiration

• CESSATION = lung re-expansion or obstruction within the system

Mediastinal Space =

bubbling & tidaling are not expected; pulsations maybe

Chest Tube Insertion
Indications

• Pneumothorax→partial to complete collapse of the lung due to accumulation of air in the pleural space

• Hemothorax→partial to complete collapse of the lung due to accumulation of blood in the pleural space

• Postoperative Chest Drainage→thoracotomy or open-heart surgery

• Pleural Effusion→accumulation of fluid in pleural space

• Pulmonary Empyema→accumulation of pus in the pleural space due to pulmonary infection, lung abscess, infected pleural effusion

Pneumothorax

partial to complete collapse of the lung due to accumulation of air in the pleural space

Hemothorax

partial to complete collapse of the lung due to accumulation of blood in the pleural space

Postoperative Chest Drainage

thoracotomy or open-heart surgery

Pleural Effusion

accumulation of fluid in pleural space

Pulmonary Empyema

accumulation of pus in the pleural space due to pulmonary infection, lung abscess, infected pleural effusion

Chest Tube Insertion
Considerations

• PRE

  • Verify the consent form signed

  • Inform the pt that breathing will improve when chest tube is placed

  • Assess for allergies to local anesthetics

  • Assist the pt into supine or semi-Fowler's

  • Prepare chest drainage system

    • Fill water seal chamber

  • Admin pain & sedation meds

  • Prep insertion site w/ providone-iodine

• INTRA

  • When chest tube is inserted:

    • Drain fluid from the lung, the tip of the tube is inserted near the base of the lung on the side

    • To remove air from pleural space = tip of the tube will be near the apex of lung

  • Assist the provider with insertion of chest tube, application of dressing to insertion site, set-up drainage system

    • Place chest tube drainage below chest level w/ tubing coiled in bed

    • Ensure tubing from bed to drainage system is straight to promote drainage via gravity

  • Continually monitor VS & response to procedure

• POST

  • Assess VS, breath sounds, SaO2, color, respiratory effort (q4h)

  • Encourage coughing & deep breathing (q2h)

  • Keep drainage below chest

  • Monitor chest tube placement & function

    • Check water seal q2h + add fluid as needed

      • fluid should fluctuate w/ respiratory effort

    • Document amount & color of drainage hourly for the first 24 hr then q8h

      • Mark date, hour, drainage lvl on container (qs)

      • Report excessive drainage (>70mL/hr) or cloudy/red drainage

      • Drainage increases w/ position changes & coughing

    • Monitor fluid in suction control chamber & maintain prescribed fluid lvl

    • Ensure regulatory dial on dry suction is at prescribed level

    • Check expected findings of tidaling in water seal chamber & continuous bubbling only in suction chamber

  • Routinely monitor tubing for kinks, occlusions, loose connections

  • Monitor chest tube insertion site for redness, pain infection, crepitus (air leakage in subq tissue)

  • Tape all connection bet the chest tube & drainage system

  • Position in semi to high-Fowler's position

  • Admin pain meds

  • Obtain chest x-ray to verify placement

  • Keep 2 enclosed hemostats, sterile water, occlusive dressing located at bedside

  • Clamped only when prescribed (e.g. air leak, drainage system change, accidental disconnection, damage of drainage) due to risk of causing tension pneumothorax

  • DO NOT clamp, strip, or milk tubing

    • only when prescribed

    • stripping creates high negative pressure & can damage lung tissue

  • Notify provider:

    • if SaO2 is less than 90%

    • if eyelets of chest tube become visible

    • if drainage is above prescribed amount

    • stops in the first 24 hr

    • if complications occur

Chest Tube Insertion
Presentation

• Dyspnea

• Distended neck veins

• Hemodynamic instability

• Pleuritic chest pain

• Cough

• Absent or reduced breath sounds on the affected side

• Hyperresonance on percussion of affected side (pneumothorax)

• Dullness or flatness on percussion of the affected side (hemothorax, pleural effusion)

• Asymmetrical chest wall motion

Chest Tube Insertion
Potential Complications

• Air Leaks

• Accidental Disconnection, System Breakage, or Removal

• Tension Pneumothorax

Air Leaks

• can result if a connection is not taped securely

• Nursing Actions:

  • Monitor water seal chamber for continuous bubbling (air leak finding)

    • Locate source of air leak & either tighten connection or replace drainage system

  • Check all connections

  • Notify provider if air leak is noted

    • If prescribed: gently apply padded clamp to determine location of air leak

    • Remove clamp immediately following assessment

Accidental Disconnection, System Breakage, or Removal

• can occur at any time & require immediate notification of the provider or rapid response team

• Nursing Actions:

  • If tubing separates: instruct to exhale as much as possible = cough to remove as much air from pleural space

  • If chest tube drainage is compromised: immerse the end of chest tube in sterile water to provide temp water seal

  • If chest tube is accidentally removed: dress the area with dry, sterile gauze

Tension Pneumothorax

• Causes:

  • sucking chest wounds, prolonged clamping of tubing, kinks/obstruction in tube, mechanical vent w/ high levels of positive & expiratory pressure (PEEP)

• Assessment Findings:

  • tracheal deviation, absent breath sounds on one side, distended neck veins, respiratory distress, asymmetry of chest, cyanosis

• Notify provider or rapid response team

Chest Tube Removal

• Assist provider w/ sutures & chest tube removal

• Instruct pt to take deep breath, exhale, bear down (Valsalva maneuver) or take a deep breath & hold it

  • increases intrathoracic pressure

  • reduces risk of air emboli

• Apply airtight sterile petroleum jelly gauze dressing

  • secure place w/ heavyweight stretch tape

• Obtain chest x-rays as prescribed

  • verify continued resolution of pneumothorax, hemothorax, pleural effusion

• Monitor for excessive wound drainage, findings of infection, recurrent pneumothorax

• Provide pain med 30 min before removing chest tubes

Chest Tube Removal
Complications

Laryngeal Edema

Laryngeal Edema

• cause of stridor (high-pitched crowing sound)

• can indicate impending airway obstruction

• Nurse must call a RAPID RESPONSE