Care of the Client with Chest Tubes

1. Care of the Client with Chest Tubes Matthew D. Byrne, RN, MS, CPAN

2. Outline • Basics • Indications • Insertion • Function

3. The Pleural Space • Space between ribs and lungs • Filled with small amount of fluid • Air or fluid in pleural space inhibits expansion and breathing

4. The Pleural Space • Physiologically, intrapleural pressure is 4-5 cm H2O below atmospheric pressure during expiration • Intrapleural pressure is 8-10 cm H2O below atmospheric pressure during inspiration • If the intrapleural pressure equals the atmospheric pressure, the lung will collapse, causing a pneumothorax

5. Chest Tubes: Basics • Used when integrity of the pleural space is lost • Loss of normal intrapleural pressures • Air or fluid may enter with loss of integrity Image from Trauma.org

6. Chest Tubes: Indications • Surgery • Traumatic chest injuries • Pneumothorax • Hemothorax • Pleural effusion (build up of fluid between the pleura) • Infection (empyema)

7. Chest Tubes: Insertion • Placed in the OR/ER/PACU or bedside • Metal trocar used as guide • Generally done with some sedation • Ideally restores negative pressure and allows air to escape/fluid to drain • Sutured to chest wall • Occlusive dressing applied • Serial chest X-Rays for progress/placement • Free end attached to drainage system • Connections are secured (taped/banded) • Pre and post vital signs and pain assessment

8. Chest Tubes: Location • To drain air: Anterior (and laterally) through 2nd intercostal space • To drain fluid/blood: Posterior through 8 or 9th intercostal space in midaxillary line

9. Chest Tubes: How they function • Drainage systems: • One chamber • Two chamber • Three chamber • Two types of suction control chambers: • 1) dry (valve/regulator) • 2) wet (water chamber) control

10. When you breathe… • When you inhale, negative pressure is created in your chest that pulls air in through your mouth/nose • What would happen if there was a hole in your chest? • A chest tube system can act as a one-way valve that can remove air/fluid • Can also be set up to create “pull” in the form of negative pressure

11. Chest tube systems • What do we need to connect to this tube in the patient’s chest? • How can what we connect collect drainage, allow air to escape and create a slight pull? • We need a three part system to do this…

12. One Bottle=One way valve • Allows air out but not in • Rise and fall of fluid with breathing (WHY? HOW?)- Tidaling • Creates no “pull” • Not intended for collection • The valve is the water • What would happen if we pulled the tube out of the water?

13. Two Bottles=Valve + Drainage • Allows air out but not in • Rise and fall of fluid with breathing • Creates no “pull” • Allows for collection Water Seal (Valve) Drainage

14. 3 Bottles=Valve + Drainage + Pull • Allows air out but not in • Rise and fall of fluid with breathing • Allows for collection • Creates a “pull” in the form of negative pressure Suction (Dry or Wet) Drainage Water Seal (Valve)

15. Commercial chest tubes Dry Suction = pressure and vacuum internally regulated Wet Suction = actual column of water used (usually 20cm)

16. In Clinical… • The units are connected to wall suction unless the order is for water seal only • Wall suction creates a vacuum, while the column of water creates the actual “pull” • Turning up the wall suction, WILL NOT increase the pull • A column of water creates pressure, much like when you are diving underwater • Therefore, increasing the column of water WILL increase the pull

17. Nursing Responsibilities • Standard 1 Assessment • Patency/functioning of system (kinks, clamps, atrium, suction, etc) • Dressings • Quantity and quality of drainage • Dependency of collection system • Coiled tubing, not hanging tubing • Pain control • Respiratory status and Vital signs (CDB/IS, lung sounds, respiratory quality/number)

18. Nursing Responsibilities • Standard 5 Implementation • Note specific orders regarding: • Suction versus water seal • Amount of acceptable drainage • I & O • X-rays • Administer pain medications regularly • Patient should change positions frequently (promotes drainage, prevents complications)

19. BSN Essentials • Critical thinking and technical skills = • Having the knowledge and skill to handle problems! • Always have at the ready: • Extra atrium/set-up • Oxygen • Suction • Occlusive dressings • Chest tube clamps • Bottle of sterile normal saline

20. Patient Ed: Standard 5BReducing anxiety… • Teach basics of drainage system, frequent checks, ask for analgesics PRN • Assure that CT is sutured in place • Remind not to kink/compress tubing • Drainage system to be kept below level of chest • Fluctuations in water seal are normal • Prepare for expected amount & type of drainage • May hear bubbling if it is a “wet” suction system • Discuss ambulating and repositioning • Plan of care

21. Chest Tubes: Removal • When “tidaling” ceases and chest X-ray/assessments confirm re-expansion of lung • Pre-medicate for pain • Breath in & hum out (have pt practice) • CT is quickly removed • Occlusive dressing applied over insertion site • Pleura seals itself off • Chest wound heals within a week