Chest Tube Care

Review of Respiratory System

• Air Movement:
    - Air movement occurs due to pressure changes between the lungs and atmospheric pressure.
    - Intrapulmonary pressure is negative during inspiration compared to atmospheric pressure.

• Pleura Layers:
    - Lungs are covered by two thin layers:
      - Visceral Pleura: Closest to the lungs and may also be called pulmonary pleura; names are interchangeable.
      - Parietal Pleura: Lines the cavity of the chest.
    - The space between these two layers is called the pleural space (or “potential space”).
    - Contains approximately 50 mL of serous fluid:
      - Allows smooth movement and helps maintain lung expansion.

Pleural or “Potential” Space

• Functionality and Features:
    - Lungs are elastic and tend to recoil; however, the pleural space keeps the two pleura adhered, maintaining negative pressure (vacuum) during breathing.
    - This adherence helps prevent friction between the lung's outer lining and the chest cavity's inner lining during inspiration.

Breach in the Pleural Cavity

• Effects of Breach:
    - A breach causes separation between the parietal and visceral pleura, allowing air to fill the potential space.
    - The following occurs:
      - The visceral pleura collapses inward with the lungs.
      - The parietal pleura recoils outward against the chest wall.
    - Medical intervention is necessary in such cases.

Pleural Complications

• Types of Complications:
    - Pneumothorax (spontaneous or traumatic).
    - Rib fractures.
    - Tension pneumothorax.
    - Hemothorax.
    - Pleural effusion.

Pneumothorax

• Definition: Occurs when air enters the pleural space.

• Classification:
    - Spontaneous
    - Traumatic
    - Other unspecified causes.

• Common Symptoms:
    - Chest pain.
    - Dyspnea (breathlessness).
    - Decrease in oxygen saturation.
    - Decreased or absent breath sounds.
    - Possible asymmetric chest movement.

• Type Classification:
    - Open vs Closed Pneumothorax.

Spontaneous vs. Traumatic Pneumothorax

• Spontaneous Pneumothorax:
    - Often caused by a small bleb (enlarged air sac on the lung's surface).
    - Commonly occurs in tall, thin males or smokers.
    - May arise from pre-existing lung conditions (e.g., emphysema).

• Traumatic Pneumothorax:
    - Caused by blunt or penetrating trauma (e.g., car accidents, bullet wounds, or stab wounds).

Rib Fractures

• Overview:
    - Most common type of chest injury due to trauma.
    - Ribs 5-10 are most frequently fractured due to less protection by chest muscles.

• Symptoms:
    - Intense localized pain upon inspiration at the injury site.

• Complications:
    - Can lead to pneumothorax or hemothorax.

Other Causes of Pneumothorax

• Invasive or Therapeutic Procedures:
    - Procedures like needle aspiration or central venous line insertion can inadvertently puncture the lung.

• Ventilator Use:
    - Patients on positive pressure ventilation with weakened lungs are at risk.

• Post-cardiac or Thoracic Surgery:
    - Pneumothorax is a common surgical complication.

Tension Pneumothorax

• Definition: Air enters the pleural space rapidly, faster than it can be evacuated.

• Consequences:
    - Pressure builds up, potentially collapsing the lung and shifting the mediastinum.
    - Can impede venous return and cardiac output, posing life-threatening risks.

• Critical Nature:
    - Immediacy required to relieve tension, as it can lead to cardiac arrest (PEA - pulseless electrical activity).

Pleural Effusion

• Definition: Accumulation of fluid in the pleural space.

• Types of Fluid:
    - Pus (empyema) due to pneumonia or infection.
    - Lymph (chylothorax), often associated with cancer.
    - Blood (hemothorax).
    - Non-specific serous fluid, commonly from heart failure.

• Pathophysiological Effect:
    - Direct compression of lung tissue from fluid accumulation.

Hemothorax

• Definition: Presence of blood in the pleural space.

• Causes:
    - Usually results from chest trauma that causes bleeding vessels to enter the pleural space.
    - Can occur as a complication from central venous access device (CVAD) insertion (iatrogenic hemothorax).
    - Common in post-cardiothoracic surgery.

Treatment of Pleural Complications

• Methods:
    - Thoracentesis: Needle aspiration to remove fluid from pleural space; requires catheter and collection system.
      - Risks include hypovolemia if too much fluid is removed quickly or potential pneumothorax.
      - Nurse’s role involves pre-medication, assisting with the procedure, ensuring comfort, and therapeutic communication.
    - Pigtail Drainage Tube: Inserted in diagnostic imaging; uses a Heimlich Valve to allow fluid or air escape without re-entry.
      - Ideal for small uncomplicated pneumothorax; does not require suction, causing less discomfort and is discreetly worn.
    - Pleural/Chest Tubes: Essential for rapid removal of fluid or air, restoring negative pressure for lung re-expansion.
      - Common size for adults is 30 Fr.
      - Quick entries facilitate normal breathing and minimize fluid accumulation post-cardiac surgery.
      - Nurses assist but do not perform insertion due to high pain and risk of organ damage.

Chest Tube Drainage Units (CDU)

• Components:
    - Collection Chamber: Where the fluid drains from the lung into the CDU.
    - Water Seal Chamber: Prevents air from re-entering; contains a one-way valve.
    - Suction Control Chamber: Regulates suction level and can connect to wall suction.

• Types:
    - Wet CDU: Uses water to control suction; pressure is determined by water level with a positive pressure relief valve.
    - Dry CDU: Uses a dial for suction control with positive pressure relief and indicates suction effectiveness with expanded red bellows.

Comparing CDU Types

• Wet CDU:
    - Water determines suction; pressure level and suction adjustments are based on water level.
    - Utilizes wall suction; includes a positive pressure relief valve.

• Dry CDU:
    - Control dial sets suction pressure.
    - Monitoring is indicated via an expanded red bellows; also features a positive pressure relief valve.

Expected Observations in a Functioning CDU

• Suction Control Chamber:
    - Gentle, continuous bubbling in a wet CDU confirms proper functioning.

• Water Seal Chamber and Air Leak Monitor:
    - Tidaling: Indicates system patentcy; rises on inspiration and falls on expiration in non-ventilated patients - opposite for those who are ventilated.
    - Absence of tidaling can signal re-expansion or clogging in tubing.
    - Bubbling: Suggests an air leak, which must be addressed.

• Collection Chamber:
    - Dark red blood is normal; bright red suggests active hemorrhage that needs medical attention if exceeding 100mL/hr post-insertion.

Chest Tube Placement

• Regarding Functionality:
    - To drain air: Place anteriorly at the 2-3rd intercostal space along the mid-clavicular line.
    - To drain fluid/blood: Place posteriorly at the 8-9th intercostal space at the mid-axillary line.
    - To drain both air and blood: One chest tube at the apex and another at the base of the lung.

Nursing Responsibilities

• Ongoing Assessments:
    - Monitor vital signs, SpO2, breath sounds, respiratory rate, effort, and chest pain to assess for respiratory distress.
    - Utilize the Pain Scale for assessing patient comfort.
    - Measure and evaluate the drainage characteristics in the collection chamber.

• Skin Assessment:
    - Examine insertion site for breakdown and palpate for edema or subcutaneous emphysema (SCE), which needs to be documented and monitored.
    - Ensure unobstructed pressure relief valves on the CDU.

• Monitoring and Interventions:
    - Keep CDU below chest level, check for air leaks or blockages in tubing, ensure adequate dressing, and facilitate ambulation.
    - Facilitate deep breathing and coughing exercises hourly.
    - Document all findings and interventions.

Nursing Responsibilities (Cont’d)

• Patient Positioning:
    - Pneumothorax: Semi-Fowler’s position for air evacuation.
    - Hemothorax or Pleural Effusion: High-Fowler’s position for fluid drainage.

Prohibited Actions

• Do Not:
    - Milk or strip chest tubes as it can cause damaging pressure.
    - Position the CDU higher than the patient.
    - Clamp the chest tube during patient transport; keep the CDU below the patient to utilize gravity drainage.
    - Remover chest tubes without certification.

Complications of Chest Tube Use

• Possible Complications:
    - Malposition of the chest tube.
    - Re-expansion pulmonary edema post drainage.
    - Vaso-vagal response causing hypotension.
    - Infection at insertion site.
    - Pneumonia risk.
    - Potential for “frozen shoulder” from prolonged immobility.
    - Risk of tension pneumothorax; continuous air leak and bleeding.

Safety Precautions at the Bedside

• Essential Items:
    - Provide two shodded hemostats (or approved clamps) taped above the patient's bed for air leak checks and physician assessments for tube removal.
    - Apply hemostatic dressings to the insertion site to prevent blood from escaping and promote hemostasis.
    - Keep a bottle of sterile water available for disconnection emergencies, which serves as a temporary water seal until re-connection.

Patient Goals for Chest Tube Management

• Objectives:
    - Promote and maintain lung expansion through various interventions, including:
      - Encouraging ambulation and regular repositioning.
      - Implementing respiratory muscle training and chest physiotherapy.
      - Engaging in deep breathing and coughing exercises to clear secretions.
      - Utilizing thoracentesis or chest tubes for drainage purposes.
      - Considering non-invasive ventilation (CPAP) and mechanical ventilation if required.