Comprehensive Study Notes on Chest Tubes and Ventilator Alarms

Definition of a Chest Tube: - A chest tube is a one-way drain that allows fluids or air to escape the pleural space.
Normal Breathing Mechanics: - Human breathing functions based on the principle of negative pressure. - Inhalation Process: When humans inhale, the diaphragm contracts and moves downward, and the rib muscles move outward. - Lung Expansion: This anatomical movement causes the lungs to expand. - Pressure Differential: As lungs expand, the pressure inside the lungs drops. This negative pressure then sucks air in from the atmosphere.
Need for Chest Tubes: - Chest tubes are required whenever the negative pressure in the pleural space is disrupted.

Definition: A condition where air is trapped in the space between the visceral and parietal pleura (the lung and chest wall).
Common Causes: - Trauma. - Surgery. - Falls. - Other mechanical injuries.
Mechanism: Outside air creates a one-way valve inside the lung, allowing air in but not out.
Clinical Manifestations (Classic Signs): - Trachea Deviation: This is a hallmark sign and a primary medical emergency. - Blood Pressure: Drops ( $\downarrow$ ). - Heart Rate: Increases ( $\uparrow$ ) as the body attempts to compensate. - Lung Expansion: Decreases ( $\downarrow$ ). - Oxygenation: Decreases ( $\downarrow$ ). - Jugular Veins: Appear distended.
Emergency Treatment: - The client requires immediate medical intervention. - Needle Decompression: Inserted into the $2nd$ intercostal space to vent trapped air. - Rationale for Chest Tube Placement: While needle decompression provides immediate relief, it is not sustainable to decompress a patient manually every several hours; therefore, a chest tube is placed for continuous drainage of air or fluid.

Every chest tube system consists of three specific chambers, each with a distinct clinical purpose:

1. Collection Chamber: - Purpose: To collect fluid or blood that exits from the pleural space. - Nursing Alerts: Notify the Healthcare Provider (HCP) if drainage is bright red (indicates active bleeding) or if drainage exceeds $100\,ml/hr$ . Drain amounts should be measured and known.
2. Water Seal Chamber: - Purpose: To allow air to escape from the pleural space during exhalation while preventing air from re-entering the pleural space upon inhalation. - Clinical Indicators: - Tidaling: A normal, positive sign where the water level fluctuates with breathing. - Intermittent Bubbling: A normal finding. - Continuous Bubbling: A sign of an air leak in the system; this is not a normal finding.
3. Suction Control Chamber: - Purpose: To control the amount of suction applied to the client. - Clinical Indicator: Bubbling in this chamber is a sign that the suction is turned on and functioning correctly.

Assessment Priorities: Monitor the client for signs of respiratory distress, evaluate breath sounds, and ensure stable vital signs.
Positional Requirement: The chest tube system must always be placed below the level of the patient's chest.
Tubing Maintenance: Never "milk" or "strip" the chest tube unless a specific order from a physician is provided.
Imaging Requirements: Daily chest x-rays are necessary to monitor lung re-expansion and check the status of fluid removal.
Site Care: Clients must have an occlusive dressing maintained at the insertion site.
Clamping Rules: Never clamp a chest tube without a direct order from a Medical Doctor (M.D.).

Scenario 1: The Water Seal is Broken: - Action: Immediately place the distal end of the chest tube into $2\,cm$ of sterile water to establish a temporary water seal.
Scenario 2: The Chest Tube is Accidentally Pulled Out (Dislodgement): - Step A: Stay calm and cover the site with a gloved hand. - Step B: Cover the opening with an occlusive dressing. - Step C: Tape the dressing on three ( $3$ ) sides only. - Rationale: Taping on three sides allows trapped air to escape while preventing atmospheric air from getting in, thereby preventing the development of a tension pneumothorax.
Scenario 3: Occlusive vs. Regular Sterile Dressing: - Critical Difference: An occlusive dressing used for chest tubes is typically covered with petroleum jelly on both sides to create an airtight seal.
Scenario 4: Client Pain and Non-compliance: - Action: Medicate the client for pain as ordered, then encourage them to cough and deep breathe to prevent the development of atelectasis.

Items ALWAYS kept at the bedside: - 1. Occlusive dressing. - 2. Petroleum gauze/sheet. - 3. Sterile water (to submerge tube if broken). - 4. Kelly clamps.
Critical Thinking: Evaluating Effectiveness: - Marking Drainage: The nurse should mark the amount of chest tube drainage at the end of every shift. - Transfer Protocol: Do NOT clamp the chest tube when transferring the patient. - Fluctuation Stops: If the fluid in the water seal chamber no longer fluctuates (stops tidaling), assess the client first; this may indicate the lung has fully re-expanded and the tube is ready for removal.
Post-Removal Care: After the healthcare provider removes the chest tube, the nurse must have a Xeroform petroleum dressing ready to place over the incision site.
Expected Lung Sounds: Prior to chest tube placement in a patient with fluid/air accumulation, the nurse would likely hear diminished breath sounds and potentially a pleural friction rub.

General Rule for Alarms: - High Alarm: Occurs when a high amount of pressure is required to deliver oxygen. - Low Alarm: Occurs when pressure is too low.
Emergency Protocol: If you cannot identify the cause of an alarm, disconnect the client from the ventilator and manually resuscitate them using an Ambu bag.
H.O.L.D. Mnemonic: - H (High Alarm): Associated with an O (Obstruction). Causes include mucus plugs, biting the tube, or blockages preventing free air flow. - L (Low Alarm): Associated with a D (Disconnection). Causes include a disconnected circuit or a significant air leak.