Clinical Indications for Chest Tube Insertion

• A chest tube insertion is medically termed thoracostomy.

  • From Greek "thorax" meaning chest and "stomy" meaning hole or opening.

• Main Purpose of Chest Tube Insertion:

  • To remove abnormal air or fluid in the pleural cavity surrounding the lungs.

  • Importance of the Pleural Cavity:

    • The pleural cavity is crucial for lung function and breathing mechanics.

    • Refer to OER Chapter 6.1 for a detailed anatomy review.

• Reasons for Chest Tube Insertion:

  • Thoracic Injury:

  • Can introduce air, leading to a condition called pneumothorax.

  • Presence of blood in the pleural cavity results in hemothorax.

  • Spontaneous Development:

  • Patients may develop fluid accumulation (pleural effusion).

  • Post-Surgical Needs:

  • Following chest or cardiac surgery to prevent fluid accumulation (cardiac tamponade).

• Mechanism of Action:

  • When a chest tube is inserted, it normalizes intra-pleural and intra-pulmonic pressures, allowing the lungs to re-expand and function correctly.

Description and Types of Chest Tubes

• A chest tube is:

  • A sterile, flexible catheter.

  • Inserted using a device (rod) into the thorax.

  • Features drainage holes at the proximal end.

• Draining Mechanism Location:

  • Air Drainage:

  • Located higher in the thoracic cavity (2nd or 3rd intercostal space).

  • Fluid Drainage:

  • Positioned lower in the thoracic cavity (posterior 8th or 9th intercostal space).

  • This positioning is to avoid puncturing surrounding organs.

• Types of Chest Tube Alternatives:

  • Heimlich Valve:

  • A small, portable, one-way flutter valve allowing discrete patient movement and use at home.

  • Pigtail Chest Tube:

  • Smaller tube length with a curly end shape.

  • Useful for air drainage (pneumothorax) but less effective for large fluid volumes.

Nursing Responsibilities Related to Chest Tubes

• Involvement Scope:

  • Nurses assist with, but cannot perform, chest tube insertions.

  • Must have knowledge for pre- and post-insertion care.

• Pre-Procedure Nursing Responsibilities:

  • Conduct assessments including vital signs and any lab results (especially arterial blood gases).

  • Prepare patient for the procedure through pain management (local anesthetic and analgesia) and correct positioning.

• Equipment Preparation:

  • Involves a clear understanding of the chest drainage system (CDU) and chest tube.

Components of the Chest Drainage System (CDU)

• Types of CDUs:

  • Wet CDU: Utilizes water to create a seal; the suction can vary.

  • Dry CDU: Uses a different mechanism for suction and does not rely on water.

Chambers in the CDU:

1. Collection Chamber:

   • Collects fluid and air from the pleural cavity, treated as an output.

   • Monitoring over 100 mL of bright red blood per hour signals a complication.

2. Water Seal Chamber:

   • Contains 2 cm of water to trap air and prevent it from re-entering the pleural space.

   • Intermittent bubbling is acceptable; continuous bubbling indicates an air leak.

   • Tidal rise and fall with respiration is observed; absence can indicate issues with the system, blockages, or improved patient status.

3. Suction Chamber:

   • Applies negative pressure to the pleural cavity to facilitate lung expansion, with preset levels based on physician order (commonly at -20 mmHg).

   • Wall suction can additionally be ordered (typically between 80 - 120 mmHg).

Emergency Protocols and Safety Considerations

• Important Actions during Emergencies:

  • If a chest tube disconnects, immediately submerge the tube in sterile water to prevent air re-entry.

  • If removed entirely, cover the insertion site with sterile gauze, creating a vent on one side to allow exhaled air out but prevent air from entering.

• Preventive Measures:

  • Do not strip or milk the tubing—this can increase pressure and cause complications.

  • Avoid routine clamping of the chest tube to prevent worsening pneumothorax.

  • Momentarily clamp only for specific situations (e.g., suspected air leak or unit change).

Assessment and Monitoring

• Routine Checks:

  • Perform assessments every 2-4 hours, including vital signs and respiratory status; document any changes.

  • Verify the integrity and positioning of the CDU; ensure it remains below chest level to facilitate drainage.

• Monitoring the Drainage System:

  • Ensure the collection chamber is upright and secure, free from blockages or dependent loops that could impede fluid drainage.

  • Observe that the water seal chamber has the correct water level and assess for bubbling to detect air leaks.

• Patient Education and Comfort:

  • Provide thorough instructions on reporting symptoms to the patient, assist with breathing exercises, and encourage mobility to prevent complications.

Post-Removal Responsibilities

• Monitoring Post-Chest Tube Removal:

  • Patients must be assessed for respiratory status and vital signs to detect any distress or need for re-insertion of the chest tube.

  • Ensure that the chest x-ray confirms lung re-expansion and monitor the insertion site for any drainage or signs of infection.